IHp^^V-^ 


— :-^ tQl> *• 

THE 

WM.  S.  HE 
Memorial  Collection 
of  Southern  History 


Presented  to 

TRINITY  COLLEGE  LIBRARY 


DATE 


By  Mr.  W.  S.  Lee,  Jr. 

r 


us  3 ,  /  <y  *-/ 


+ 


AN 

E  P  I  T  0  M  E 


OK 


PRACTICAL  SURGERY 


FOB 


FIELD  AND  HOSriTAL. 


EDWARD  WARREN,  M.  D. 

.!    OF  THE  STATE  OF   NORTH   CAROLINA,   l'OKMEItKY 
•  t  IN  THE  UNIVER6]  .V  OF  MARTI. AND. 


FRIST   EDITION. 

RICHMOND,  VA. 

W  !•:  ST  &  J O H  N  s TON,  11  5  .  M  A  1  N  S T  R  E  E T 
1863. 


Entered  according  to  Act  of  Congress,  in  the  year  1863,  by 

EDWARD  WARREN,  M.  D., 

1*  the  Clerk's  Office  of  the  District  Court  of  the  Confederate 

States  for  the  District  of  Pamlico,  North  Carolina. 


BROTHER  k   MARCOM,   PRINTERS,    HALK1UH,     N.    C. 


3"^ 

TREASU**  ftU. 

£rv  tf  £ 


TO 


LAFAYETTE    GUI  L  0 . 
JHurr/fcm    C.   8.  A. 

ANU 

JOSEPH    P .    LOGAN, 

Surgeon  J1.  A.  C".  >S'. 

8£his  tuorh 

IB    iMOST    RESPECTFULLY    AND    AFFECTIONATELY 
DEDICATED. 


PREFACE. 


Much  experience  in  Field  and  Hospital,  has  convinced  mo 
of  the  necessity  for  the  publication  of  a  work  on  Surgery, 
more  elementary,  practical  and  concise  in  its  character  than 
has  hitherto  appeared.  I  have  therefore,  devoted  myself  to 
the  preparation  of  this  volume,  as  a  vade  mecum  for  tin 
geons  of  the  Confederate  service,  with  the  view  of  supplying 
the  desideratum  which  exists  in  this  regard. 

.Little  claim  to  originality,  either  as  to  principles  or  details, 
is  advanced  in  these  pages;  but  I  have  mainly  endeavored 
to  glean  from  fields  of  experience  far  richer  and  broader  than 
ray  own,  such  views,  facts,  and  deductions  as  are  most  worthy 
of  diligent  study,  and  faifjhful  preservation.  The  ablesl 
authors  ou  the  various  Bubjecta  discussed,  have  been  freely 
consulted,  and  the  intelligent  reader  will  have  no  difficulty 
in  discovering  to  what  extent  I  am  indebted  to  them  for  the 
substance  matter  of  this  volume.  Wherever  an  issue  has 
been  made  with  standard  authorities,  it  has  been  from  an 
honest  conviction  of  the  absolute  necessity  for  such  a  course, 
and  from  an  earnest  desire  to  advance  the  best  inten 
Surgical  science. 

So  far  as  the  typographical  execution  of  this  book  i-  con- 
cerned, I  must  urge  in  extenuation  of  its  imperfections,  thai 
the  best  printers  are  in  the  service,  and  that  thoee  who  re- 
main behind  are  too  young  and  inexperienced  to  do  proper 
justice  to  any  author.  For  this  reason  many  errors  will  he 
found  in  this  etfition  which  ahall  he  corrected  in  a  subsequent 
one. 

For  the  invaluable  statistical  information  contained  in  thu 
Appendix,  I  am  indebted  to  the  courtesy  of  Surgeon  Samuel 
Preston  Moore,  Surgeon  General  of  the  Confederate  St 
under  whose  intelligent  scrutiny  and  able  direction    it  was 
carefully  collected  by  Surgeon  Francis  Sorrell,   tn 
Hospitals  for  the  City  of  Riohmond. 


Vi  PBBFACS. 

Whatever  the  raeritg  or  defects  of  this  unpretending  work, 
ii  has  been  undertaken  in  a  spirit  of  loyalty  and  humanity  >. 
and  it  is  now  issued  with  the  hope  of  contributing  something 
te  a  cause  in  which  every  sentiment  of  my  bosom  is  moat 
warmly  enlisted. 

Should  it  be  the  means  of  saving  a  single  life,  of  alleviating 
a  pang  of  pain,  or  of  inspiring  one  professional  brother  with 
a  braver  heart  and  a  steadier  hand  in  the  hour  of  trial,  my 
proudest  aspiration  will  be  more  than  realized. 


INDEX 


PAOZ. 

Abscesses,               ........  is 

Accidents  after  Amputations, 116 

Acupressure,           -                 -  '22£ 

Alteratives,             ..--.--_  78 

Amputation,  varieties  of 81 

"             primary,           -      <  -         -         -         -  81 

seco»dary,              87 

"             modes  ol,          ..-..-  104 

of  great  toe,         -  137 

of  metatarsal  joint  -----  138 

of  metatarsal  bones,    -        -        -        -  138 

tbrougb  tarsus, 139 

at  ankle  joint.       -----  140 

"            of  leg, 14'J 

"            at  kmee  joint, 144 

'•           of  thigh, L46 

at  hie  joint.           -----  152 

ot  fing?ra,         ......  155 

"             at  wrist  joint, 158 

of  fore  arm,     ------  159 

at  elbow  joint,      -----  160 

"            of  upper  arm.            ....        -  161 

at  shoulder  joint.         ...         -  102 

Anremia  ti-om  loss  of  blood.        -----  -JO^ 

Antiplogistic  regimen,  -------  62 

Applications,  cold  and  warm. 73 

Arteries,  structure  of, 239 

compression  of,   -         -        -        -        -        -  218 

ligation  of. 235 


Vlll  INDEX. 

"page. 

Arteria  innominata,             266 

Anterial  sedatives,          - "       -      .  -        -        -        .        -  57 

Axillary  artery,            ---.__.  268 

Barton's  fracture, :}7G 

Blisters, -'__'.  71 

Blood,  changes  in,          -------  13 

"      condition  of, 4  213 

Blood  letting,         -         -         -         -         -        -    .    -  54 

Bones,  exoisio»  of,     -         -         -         -        -        -         -  .101 

"      reproduction  of, 203 

fractures  of,     -         - 340 

Brachial  artery,     -        -        -         -        -        -         -        -...27 

Brainard's  perforator,          ------  348 

Carreer.           -_-._-_--  43 

Causes  of  Hemorrhage,       -        -        -        -        -        -  211 

Carpal  bones,  dislocation  of,           -----  323 

"          "      fractures  of,           -  379 

Carotid  artery,        -■-'.- 247 

Circular  method  of  amputation.           -  104 

Colle'p  fracture. -  376 

Comminuted  fractures, 342 

Complicated  fractures, -        -  '■'^- 

Compound  fractures,  -------  342 

"                '■        of  inferior  raaxillary,      -  303 

"                 "         of  arm,         ....        -  378 

of  hand,  -         -         - 

"                 '•         of  ribs,          -  366 

of  pelvis,          -        -        •        "        -  376 

"        of  thigh,       .----  383 

"                ^        of  leg.              s  388 

offoot,        -----  301 

Compression  of  Arteries,          -  217 

"           of  brain,  --.-*-'  351 

Concussion   of  brain,       -                                            -  °°* 

Corpuscles,  red,  .-.----"  *° 

"           white,  -------  13 

Depletory  remedies,    -------  54 


INDEX.  IX 

PAGE 

Depression  of   bone,        - 339 

I  Msarticulation  of  fingers,    ------  157 

Dislocations,  ---------  295 

of  lower  jaw. 308 

Dislocations  of  clavicle,     -----    310 
"  of  acromion,       -  312 

of  shoulder  joint,      -  -  -  .     313 

of  ulna,  -  -  -  -  -  318 

of  radius,      -  -  -  -  *    318 

of  wrist,  ...  -  322 

of  thumb,     -----    324 
of  thigh,  -  -  -  •  326 

of  patella,      -----    ;;;;:; 
"  of  tibia,  -----  333 

of  fibula,         -  .  -  -  • 

of  astragalus,     -  .  -  -  336 

ofcalcaneum,  -  -  -  -     337 

Effects  of  gun-shot  wound-.  ■  -  -  356 

Erysipelas,  -  -  «  .  -  .123 

Extension  and  counter  extension,      -  -  -  304 

Fever,         -  -  -  -  .  -  -26 

Fissures  of  bone,         -  369 

Flaps,  length  of,   -  .  -  -        .    -  -     L09 

Flap  amputations,       -  -  -  -  ■  ;  105 

Flexion  of  bones,     ----:-'-     389 
Fractures,  classification  of.  -  -  328 

"         of  pelvis.  ...  -     370 

"        of  humerus,  ....  370 

"        of  ulna,  -  -  -  -  874 

''         of  clavicle, 

"        of  scapula.  -----    653 

"        of  cratiial  bones,    -  -  -  -  350 

of  radius,  -----    375 

of  ulna  andjradius,  -  -  -  376 

of  carpal  boues,  •  -  -  -     379 

of  fingers,  -  -  -  -  378 

Of  feraur.  -  -  -  -  .37V 


X  INDEX. 

f  AGE. 

Fractures  of  patella,  .....  387 

of  tibia,               .            -■-                     -  -    380 

of  fibula,     -----  380 

"        of  fibula  and  tibia,        -  370 

"        of  bones  of  foot,  300 

Gangrene,  .....     \gg 

Giiaglymoid  joints,      -            *            -            -            -  U93 
Hemorrhage,         -                         ....     210 

Hemorrhagic  fever,  -----  208 

Hernia  cerebri,       -            -            -            -            -  - "  361 

Hospital  gangrene,    -----  120 

Inclined  plane,      ------    3S2 

Induration,     -.--.-  37 

Inflammation,        -----  .13-70 

ligation  of  arteries,               ...  226 

"        of  arteria  innominata.               -            -  -     246 

"        of  common  carotid,            -            -            -  247 

"        of  exterior  carotid,       -  250 

of  thyroid.  -----  252 

of  lingual.           -            -   •                   -  -     252 

of  facial,      -  253 

"        of  subclavian,     -           •            ...  .    255 

of  axillary,              -  268 

of  brachial, 271 

"        of  radial,     -----  275 

''        of  ulna,  -            -            '                        -  -    278 

"        of  common  iliac,    -  356 

"        of  external  iliac,            .  264 

"         of  internal  iliac.     -."■--  262 

of  femoral           -            -            -  -     280 

"        of  popliteal,            -            -                        -  285 

"         of  posterior  tibial,          -  291 

"        of  anterior,  tibial.              -            -            -  287 

"        of  dorsalis  pedis,            .  389 

"        of  peroneal,            f           -                        -  289 

Ligatures,  mediate  and  immediate,        -            -  -    226 

Litters.           ------  346 


VR  D&X .  xi 

PAGE. 

Litter  Corpa,         .--...  344 

Lymph,  absorption  of.           -            -            -            -  36 

Malar  bone,  fracture*  of  -            -            -            -            .  283 

Median  Baailie  Vein.             ...            -  074 

Mercury.         -                     -            -            -            •            -  57 

Morphia/ — Endermic  use  of    -           -            -            -  306 

Nervous  Sedatives,  -  .  -  -89 

Opium,      -*--••-  59 

Organization  of  Lymph.               ....  40 

Orbicular  Joint*,        -----  298 

Oval  method  of  Amputation.       -  106 

Palmar  aroh,               -            -            .            .            .  279 

Point*  for  ligature?.          .....  235 

"        of  stagnation.               -             -             -            -  14 

Position  in  hemorrhage.               ....  221 

"  inflammation.        -             -            -             -  71 

Pullies  compound,              .....  328 

Pus,     ---.---  40 

Pyaemia,  .               ......  127 

Pyogenic  membrane.,               -  39 

Rtdness,      -            -            -            -            *            -            -  18 

Resections  in  genera],            .  180 

Bwiection  of  meta:  carp  :  phal :  articulation,     -            .  180 

"          "  meta:  carp,  bones,      -            -            -  180 

'«          "  wrist  joint.              -               -             -            -  180 

"  radiui,                                       -           -  181 

"          "  ulna,              -                         -                          -  182 

"  elbow  joint,                    -            -            -  183 

"  shoulder  joint.          .            -                        -  185 

"  clavicle,             -                       -  190 

"  scapula,         -                                    -            -  190 

"  tarsus,                 -                                    -  191 

"  ankle  joint,               -                                   -  192 

"knee  joint,  192 

"  hip  joint,                                                      -  199 

JUaolution,         ...            -  36 

R«vui«iv««,              -                        -            -            -            -  77 


Xli  INDEX. 

PA.GB. 

Saline  elements,          -            .            -            .            -  14 

Seton,                       -  .     228 

Shock,             -           -           -           -           -           -  120 

Smith's  ant:  splint,          -              -,'-..-  386 

Statistics,           ---...  392.400 

Stumps  conical,              ,   -            -            -            -  -     119 

"         neuralgia  of,               -           -           -            -  120 

Structure  of  arteries,             -  239 

Swelling,                          -            -            -  20 

Styptics,          ----..  -    236 

Suppuration,         -                      -             -             -             -  139 

Tetanus,         -  -----     131 

Tourniquets,         -                     -            -            -            .  217 

Transformation  of  tissue,             -             -            -  -      45 

Trephining,                   -----  169 

Warm  applications.            -             -            -            -  -     75 

Water  dressings,  74 

Wounds  of  head,         -       -            -            -            •  -     355 

"     offace,        -              .  862 

"      of  lungs,                 -  -     368 

"     of  arteries,                 -                        -            -  208 

"     of  soft  parts,  generally,               -            -  -    357 

"      bones,                         -            -            -  356 
"      entrance.               -----     353 

"     exit,                                        -            -  358 

Wounds  from  round  balls,             -            -            -  -     357 

"            "     conical  balls,                 .            -            -  358 
"           "     swords.         -----    352 

Ulna,                            -----  313 

Venesection  in  lung  wounds,          -  668 


E  R  R  A  T  A  . 

Page     10,  T2th  line,  last  word",  read  "inflamed." 

"      58,     9th  "     next  to  last  word,  read  "relieving." 

"     132,  18th  "     after  principle,  read  "  nerve." 

'■     146,13th  "     for  "60,"  read  "50  percent." 

"     176,  31st  "     for  "  only,"  read  "  generally." 

"    252,  14th  "     for  "antrim,"  read  "antrum." 

"    285,10th  "     for  "abductor,"  read  "adductor/" 


CHAPTER  J. 


INFLAMMATION. 

Definition. — Inflammation  is  a  condition  of  al- 
tered nutrition  in  which  a  perversion  of  the  Blood 
and  Blood  Vessels  occurs,  accompanied  by  increas- 
ed vascularity,  augmented  sensibility,  change  in 
secretion,  an  exudation  of  Liquor  Sanguinis,  and 
a  modification  of  structure  and  of  function. 

Changes  which  take  place  in  the  Blood. — The 
blood   becomes   //';,  pvas   first  established 

by  1  Cewson. 

The  J?t\l  Corpuscles  are  increased  in  quantity  in 
the  early  .stages  of  inflammation,  bu1  are  subse- 
quently decreased  as  the  disease  advances.  They 
also  have  a  tendency  to  elm  ether,  by  the 

cohesion  of  their  tlat  surfaci 

The  White  Corpusci  are  largely  increased  in 
number,  ami,  by  adhering  to  the  walls  of  the  vessel, 
tend  to  arresl  the  circulation. 

The  Liquor  Sa  —Andra]   ami  ( 

have  shown  that  Fibrin  may  he  increased  \ 
high  as  i!  per  1000 — an  augmentation  whi 
manifestly  din1  to  the  more  rapid  ami  ci  met- 

amorphosis which  takes  place  in  the  fthe 

part.     But  by  far  the  most  remarkable  and  impor- 
tant fact  which  man  if  sts  itself  in  this  r 
the  tendency  to  effusion  which  is  devi 
disease  advances.    The  Liqn  . 


14  CHANGES  IN  THE  BLOOD. 

ironi  the  vessel  and  disseminates  itself  through 
the  surrounding  tissues,  either,  to  be  subsequently 
re-absorbed,  to  organize,  or  to  break  down  into 
purulent  matter.  This  exudation,  according  to 
Virchow,  is  the  essential  element  in  the  inflamma- 
tory process,  giving  character  to  it,  and  furnishing 
the  most  reliable  index  as  to  its  pathology  and 
treatment. 

The  Saline  Elements  are  somewhat  below  tbe 
normal  standard,  while  the  proportion  of  water  is 
perceptibly  increased. 

The  Coagulation  of  i  nflammatory  bl  ood  takes  place 
more  slowly,  while  the  coagulum  is  harder,  and 
smaller,  and  the  quantity  of  serum  greater  than 
under  ordinary  circumstances.  The  upper  surface  of 
the  coagulum  is  covored  with  a  layer  of  yellow 
fibrinous  matter,  known  as  the  butty  coat,  and  de- 
pressed in  its  centre  in  the  form  of  a  cup. 

The  Buffij  Coat,  is  regarded  as  an  index  and  rep- 
resentative of  the  intensity  of  the  inflammation, 
though  the  test  is  by  no  means  infallible,  in  as 
much  as  the  same  phenomenon  is  manifested  in 
Rheumatism,  Pregnancy,  and  Plethora,  in  all  their 
stages  and  conditions,  without  regard  to  tbe  extent 
of  the  inflammatory  process. 

Points  of  Stagnation  may  be  found,  upon  a  close 
examination  of  the  inflammed  tissue,  at  which  the 
blood  current  appears  to  ebb  and  flow,  until  it  is 
finally  and  permanently  arrested.  This  stagna- 
tion usually  occurs  in  those  capillaries  which  are 
not  directly  located  between  arteries  and  veins, 
and  results  from  adhesion  of  the  Tied  Corpuscles 
and  the  consequent  blocking  up  of  the  vessels  by 


CHANGES    IN  BLOOD  VESSELS.  15 

the  masses  thus  formed.  It  is  at  these  points  also, 
that  the  drawing  away  or  exudation  of  Liquor  San- 
guinis usually  commences,— 'facilitating  the  coal- 
lescence  of  the  corpuscles,  and  indirectly  contribut- 
ing to  the  arrest,  of  the  blood  current  at  the  par- 
ticular localities  in  question".  Wherever  this  re- 
tardation of  the  circulation  occurs,  the  white  cor- 
puscles may  likewise  be  found  in  great  quantities, 
either  rolling  slowly  along  the  walls  of  the  vessel 
or  closely  adhering  to  them. 

CHANGES  MUICll    TAKE   PLACE  IX    THE  BLOOD  VESSELS. 

— The  arteries,  capillaries  and  veins  are  usually 
contracted  in  the  first  instance,  but  are  subse- 
quently enlarged. 

The  Arteries  leading  to  the  part  are  especially 
dilated,  while  their  coats  are  relaxed,  so  that  the 
pulsations  within  themare  stronger  and  more  per 
ceptible. 

The  vessels,  in  consequence  of  this  dilatation, 
actually  convey  more  blood  to  the  inflammed  part, 
than  under  ordinary  circumstances,  as  has  been 
repeatedly  demonstrated. 

In  consequences  of  the  expansion  of  the  smal 
ler  arteries  and   capillaries,    red    corpuscles    arc 
more  freely  admitted,  so  that  the  part  becomes 
wd,  as  it'  from  the  development  of  new  vessels. 

The  arteries  are  not  only  dilated,  but  become 
elongated,  tortuous,  and  waving — increasing  in 
length  as  well  as  in  circumference,  while  smal! 
brandies  project  from  their  walls,  and  fusiform 
dilatations  of  the  whole  diameter  frequently  pre- 
sent thei 


16  CHANGES  IN  THE  SYSTEM. 

The  distention  of  the  arteries  and  capillaries 
before  the  point  of  obstruction,  induces  increased 
effusion  of  serum,  lymph,  and  pus. 

The  veins  beyond  the  point  of  obstruction  are 
empty;  and,  hence,  there  is  increased  absorption 
with  softening  &c. 

The  circulation  at  the  point  of  obstruction  is 
arrested,  so  that  there  is.  a  reduction  or  abolition 
of  the  vital  properties;  and  consequently,  either 
gangrene,  ulceration  or  suppuration  is  developed. 

There  is  also  increased  circulation  of  the  blood 
around  the  point  of  obstruction,  causing  exaltation 
of  the  vital  properties;  and,  hence,  spasm,  pain, 
sympathetic  irritations,  increased  secretion  &c, 
are  produced. 

CHANGES    WHICH    ARE  INDUCED    IN  THE    SYSTEM  AT 

large. — The  excitement  may  extend  to  the  heart 
and  arteries,  causing  inflammatory  fever". 

The  whole  mass  of  blood  may  undergo  altera- 
tions by  increase  of  fibrin,  by  diminution  of  the 
secretions,  and  by  the  retention  in  the  circulation 
of  their  elements. 

Exhaustion  ensues  after  excessive  excitement, 
the  effusion  of  serum  or  the  formation  and  escape 
of  pus. 

Depression,  with  partial  irritation,  not  unfre- 
quently  supervenes  in  consequence  of  the  pre- 
sence ot"  pus  in  the  blood.  Th.ough._the  pus  globu- 
les cannot  be  absorbed  into  the  blood  by  reason 
of  their  size,  in  their  normal  state,  yet  certain 
modifications  take  place  in  them,  under  some 
circumstances,  which  do  admit  of  their  being  taken 
into  the  circulation,— causing  the  development  of 


CAUSES.  17 

peculiar  and    the   induction   of    fatal 

consequences. 

causes  of  inflammation. — The  causes  of  inflam- 
mation may  be  divided  into  predisposing  and  exci' 
ling.  **• 

Predisposing  causes  act  both  locally  mid  generally. 
The  general  or  constitutional  predisposing  cause.-, 
are  plethora ;  excess  in  food,  or  bodily  exertion; 
exposure  to  miasmatic  influences;  disorders  of  the 
liver,  skin  and  kidneys;  great  mental  emotion; 
over  stimulation  ;  vascular  and  nervous  depression 
&C. 

The  local  predisposing  causes  are,  excessive 
use  of  the  part ;  previous  injury  or  disease  ;  deli- 
cacy of  organization  &c. 

The  exciting  causes  are,  mechanical  injury;  chem- 
ical agencies;  morbid  poisons;  and  certain  impon- 
derable agencies,  as  beat,  cold,  galvanism  &c. 

The  causes  of  inflammation  may  produce  their 
legitimate  results  either  directly — that  is  to 
by  irritating  and  inflamming  the  part  with  which 
they  are  in  contact — or  indirectly  through  the 
icy  or  instrumentality  of  nervous  reflex  action^ 
as  when  cold  applied  to  the  feet  causes  inflamma- 
tion o\'  the  lungs,  bowels,  or  peritoneum. 

The  causes  of  inflammation  are  common  or 
specific,-  the  former  being  of  constant  occurrence, 
and  a  -iitutions  equally, — the  !. 

being  pctai liar  in  their  origin,  action  and  effects 
upon  the  human  economy. 

mmation. — The  symptoms  or 

•  by  which  inflammation  is  distinguished  are 

•  lend.— that   is  to  say,  connect   -them- 


18  SYMPTOMS. 

selves  both  with  the  part  aftected  and  with  the 
system  at  large. 

Local  Symptoms. — The  symptoms  of  inflamma- 
tion which  connect  themselves  with  the  part  afiect- 
ed, are  reclifrss,  pain,  heat,  swelling,  alteration  of 
structure  and  changes  in  function. 

Redness — This  is  owing  to  the  primary  production 
of  a  greater  number  of  red  corpuscles  than  usual; 
to  the  enlargement  of  the  vessel,  permittiug  red 
corpuscles  to  circulate  more  extensively  through 
them;  and  to  the  presence  in  the  part  of  an  unu- 
sual amount  of  blood. 

Pain. — This  is  due  to  the  tension  of  the  nervous 
ii laments  directly  involved;  to  the  greater  irrita- 
bility of  the  whole  nervous  mass;  and  to  the  aug- 
mented susceptibilities  of  the  sensorium.  There 
are  different  varieties  of  pain.  Thus,  it  is  dull 
obtuse,  heavy  or  aching  in  congestions,  and  chronic 
inflammations,  or  in  acute  inflammations  of  pa- 
renchymatous, organs:  it  is  gnawing  or  lacerating 
in  rheumatism,  gout,  and  periostitis :  it  is  lanci- 
nating in  scirrhus  or  in  inflammations  of  the  nerves  : 
it  is  twisting,  griping  or  spasmodic  in  dysentery, 
ileus,  gastralgia,  and  obstruction  of  the  intestines: 
it  is  burning  as  in  cutitis,  and  erysipelas:  it  is 
sharp  and  cutting  in  inflammations  of  serous 
membranes  :  and  it  is  oppressing  in  inflammations 
of  the  stomach,  testicles,  liver,  and  kidneys. 

Pain  is  riot  an  invariable  concomitant  of  inflam- 
mation. Thus  it  is  absent  when  inflammation 
only  ends  in  adhesion  ; — when  the  inflammatory 
action  is  indolent,  as  in  scrofula ;  when  both  the 
mental  and  physical  susceptibilities  have  been 


SYMPTOM?.  1 9 

destroyed,  as  by  the  abuse  of  spirituous  liquors, 
opium  and  tobacco, — the  exhibition  of  chloroform, 
or  the  existence  of  that  peculiar  morbid  condition 
which  is  denominated  insanity;  when  the  nervous 
centres  have  lost  their  normal  irritability  or  re- 
sponsive power,  in  consequence  of  the  absorption 
of  some  "blood  poison,"  or  the  retention  of  the 
elements  of  the  bile,  urine,  &c;  and,  when  the 
connexion  between  the  brain  and  the  affected  part 
is  destroyed,  as  by  the  destruction  of  the  nervous 
filaments  serving  as  their  bond  of  union. 

Heat. — The  amount  of  heat  in  an  inflammed 
part,  is  never  so  great  as  the  patient  supposes, 
though  it  has  been  established  by  the  experiments 
of  Becquerel,  and  Breschet,  that  Celsus  and  Hunter 
were  correct  in  regarding  elevation  of  temperature 
as  a  characteristic  of  the  inflammatory  process. 
The  temperatura,of  the  foci  of  inflammation  is  to 
be  regarded  as  the  expression  of  several  distinct 
sources  of  heat,  viz  : 

1.  From  the  blood  which  accumulates  in  an 
unusual  quantity  about  the  centre  of  irritation. 

2.  From  the  increased  metamorphosis  of  tissue 
which  tal;.'-  place  in  consequence  of  this  accumu- 
lation of  blood,  and  the  attendant  superabundance 
of  those  elements  whereby  the   structures  ar< 

ne  wed. 

'■'•.  From  thr  more  active  metamorphosis  of 
tissue  which  is  induced  by  specific  changes  in  the 
nervous  status  of  the  part. 

The  blood  is  warmer  than  the  subjacent  tissues, 
and  hence,  there  must  bo  more Jieat al  those  points 
where  this  fluid  accumulates.     Again,  as  i'  is  now 


tfPTQMS. 

placed  beyond  question,  that  the  source  of  the 
normal  animal  temperature  is  to  be  found  in  the 
chemical  development  of  heat  attendant  on  nutri- 
ent changes  continually  occurring  in  the  tissues, 
it  follows  that,  where  there  is  an  elevation  of  tem- 
perature, there  must  also  be  increased  metamor- 
phosis. 3STow,  this  increased  metamorphosis  be- 
comes a  matter  of  necessity  when  an  unusual 
supply  of  pabulum  is  presented,  as  is  the  case  where 
blood  accumulates  in  tissues  which  have  at  once 
an  appetite  for  it,  and  the  power  of  appropriating 
it  according  to  their  necessities. 

And  lastly,  the    experiments   of  Bernard   and 
Sequard,  have  clearly   established,   that  this   ap- 
petite of  the  tissues,  or  in  other  words,  their  forma- 
tive power,  or  metamorphic  capability,  can  be  in- 
creased or  diminished  according  to  the  amount  of 
nervous  influence  supplied   to   them.     It   follows 
therefore,  that  when  there  is  an  excess  of  pabul  um — 
i  as  must  occur  when  the  circulation  is    more  rapid 
than  usual,  or  there  is  an  increase  of  blood  in  the 
part    from    any    cause,    and   such   a  concurrent 
change  in  its   nervous   condition   takes   place   as 
tends   to   stimulate  its    nutritrivu   power, — there 
must  be  a   more  rapid  and  complete    metamor- 
phosis, and  a  corresponding  elevation  of  tempera- 
ture. 

oiling.— This  is  caused  at  first  by  the  increas- 
ed quantity  of  blood,  and  subsequently  by  the 
effusion  of  lymph,  the  pouring  out  of  serum,  or  the 
formation  of  pus.  The  more  dense  the  texture, 
the  less  there  is  of  swelling,  and  vice  versa. 

Alteration  of  Function. — Each  tissue   and  every 


SYMPTOMS.  2 1 

organ  has  a  certain  part  to  perform  in  the  econo- 
my, which  is  its  contribution  to  the  completeness 
and  perfection  of  the  organism.  This  is  known  as 
the  function  of  the  part.  Thus  the  function  of 
muscular  tissue  is  to  contract,  and  of  glands  to  se- 
crete.  Now,  a  given  tissue  requires  two  things  par- 
ticularly, in  order  to  secure  the  proper  perform 
of  its  appropriate  function,  viz  :  the  distribution  to 
it  of  a  certain  amount  —  neither  too  much  nor  too 
little — of  nervous  influence;  and  the  preservation 
of  its  structure-  in  their  normal  condition,  [n- 
flammation,  as  previously  shown,  not  only  changes 
the  n*  of  the  part,  hut  constitutes  per  se 

such  a  veritable  perversion  of  its  nutrition,  as 
speedily  induces  a  positive  modification  of  its 
structure. 

It  thus  becomes  plain,  that  inflammation,  must, 
as  a  matter  of  necessity,  materially  interfered  with 
the  function  of  the  part  in  which  it  has  been  pro- 
duced, while  all  experience  confirms  the  truth  of 
this  deduction. 

It  is  in  this  way  that  alteration  of  secretion 
ensues.  Thus,  secretion  is  usually  diminished  at 
the  commencement  of  inflammation,  susp< 
when  it  is  at  its  acme,  and  increased  at  H 
health  be.  the  termination.  In  the  same  manner, 
•lions  may  change  their  character.-  chemically, 
or  become  mixed  with  the  produqts  of  inflamma- 
tion, as  pithelial  cells,  tube  cast. 
lymph  and  pus. 

Alterations  in  Structure.- -These  taketp]ace  in 
consequence  of  the  alteration  in  the  nutrition  of  the 
part.     The  various  tissues  of  the  body  are  differ- 


22  SYMPTOMS. 

ently  affected  by  the  inflammatory  process,  as  will 
be  shown  hereafter,  but  there  are  certain  changes 
common  to  all  of  them,  which  ma}r  be  mentioned 
here.  The  weight  is  usually  increased,  unless  apo- 
plexy be  produced  :  hardness  is  diminished, — that 
is,  there  is  less  of  cohesion  in  the  part,  because  of 
the  effusions  which  infiltrate  its  tissues.  In  chronic 
inflammations  the  opposite  of  this  is  frequently 
the  case,  inasmuch  as  the  effused  lymph  organizes, 
or  the  whole  limb  may  become  shrunken  :  Trans- 
parency is  destroyed  .  Polish  is  impaired  mate- 
rially: and  alterations  may  take  place  in  all  the 
physical  properties  pertaining  to  the  tissue. 

General  or  Constitutional  Symptoms. — The  most 
promenent  and  important  of  these  is  fever.  Fever 
and  inflammation  are  processes  that  many  con- 
found with  each  other,  though  they  are  really  dis- 
tinct. They  may  alternate  or  be  intercurrent; 
and  on  the  other  hand,  their  characters  and  pheno- 
mena may  be  so  blended  as  to  render  it  a  matter 
of  impossibility  to  draw  a  line  of  demarcation  be- 
tween them,  and  even  to  necessitate  the  use  of  a 
mixed  term  to  define  the  resulting  condition.  It 
is  in  this  way  that  the  expression  Inflammatory 
Fever  has  obtained  a  place  in  the  vocabulary  of 
medicine;  and  yet,  whatever  may  be  the  analogy 
between  them,  or  however  undoubted  the  fact  of 
their  simultaneous  existance  at  certain  times,  it  is 
impossible  to  deny  that  they  differ  in  their  essen- 
tial nature,  and  that  they  are  totally  distinct  pro- 
cesses. 


vm  PTO 

Points  of  Resemblan  and  Inflam- 

mation.— The  following  characteristics  distinguish 
both  of  them: 

1.  An  elevation  of  the  animal  temperature,  such 
as  can  be  distinguished  and  measured  by  the 
thermometer. 

2.  An  acceleration  of  tissue  metamorphosis  of  a 
decided  and  appreciable  character. 

3.  An  increased  rapidity  of  the  circulation  and 
definite  changes  in  the  nervous  system,  as  have  al- 
ready been  referred  to,  and  as  will  be  more  tally 
explained  hereafter. 

Points  of  Different  betw  nd  Inflamma- 

tion. 

1.  Inflammation  is  usually  of  local  origin,  jvhilst 
fever  irally  of  systemic  origin,  and  in  its 
course  involves  the  whole  organism. 

2.  In  Inflammation,  the 'attending heat,  acceler- 
ation of  metamorphosis,  excitement  of  circulation 
and  change  of  nervous  status  is  localized  :  while 
in  fever  these  conditions  are  produced  generally 
and  simultaneously  throughout  the  system. 

3.  Tn  Enflamation  metamorphosis  is  induced  in 
the  tissues  even  to  the  extent  of  their  disorganiza- 
tion. In  Fever,  the  nutrient  local  changes,  t  hough 
accompanied  by  interstitial  absorption,  progress, 
both  in  tissues  and  organs,  without  material  inter- 
ference with  their  functions. 

I.  [nflammation  usually  results  as  the  effect  of 
some  mechanical,  or  chemical  cause,  acting  upon 
the  animal  structures,  and  i  an  be  produced  at  will. 
Fever,  on  the  other  hand,  is  produced  by  causey 
which  can  be  neither  explained  nor  controlled. 


tfPTOMS. 

5.  The  Inflammatory  process  can  be  checked, 
controlled  or  modified  by  the  employment  of  pro- 
per therapeutical  agents;  while,  of  most  fevers,  it 
mavbe  asserted,  that  they  are  self-limited,  and  that 
any  attempt  to  cut  them  short  must  fesult  in  failure 
as  a  matter  of  necessity. 

In  this  connexion,  Lyons,*  uses  the  following 
appropriate  and  significant  language:  "  While  I 
believe  it  may  be  said  with  truth  that  we  can  cure 
many  Inflammations  by  the  intervention  of  art,  the 
same  cannot  be  affirmed  of  Fevers.  In  Fevers  the 
highest  efforts  of  our  art,  the  most  delicate  can.'. 
the  most  refined  skill,  the  most  nice  appreciation 
and  adaptation  of  means  to  ends  which  we  can 
comjnand,  must  be  all  directed  to  watching,  sup- 
porting, maintaining,  and  it  may  be  stimulating 
the  system  till  the  fever-storm  shall  have   passed 

over  it." 

Circumstances   under  which  fever  is  not  readily 

produced. 

1.  "When  the  Inflammatory  process  limits  itself 
;y  to  the  repair  of  tissues,  Fever  is  not  one  of 

its  attending  phenomena. 

2.  When  it  is  circumscribed,  that  is,  when.  but. 
a  small  portion  of  the  animal  structure  is  involved, 
Fever  is  not  ordinarily  developed. 

3.  When  it  occurs  in  tissues  of  an  inferior  de- 
•  of  vital  organization,   the   svstem   does   not 

respond  to  the  local  impression,  and  that  reaction, 


*A  Treatise  on  Feyer  &c,  by  Robert  D.  Lyons,  K.  C.  C.  D. 
D.     Blanchard  k  Lea,  Philadelphia,  1861.     To  this  admirable 
:':■:,  we  are  indebted  to  many  i'or  the  above  views. 


SYMPTOMS.  25 

which  we  denominate  febrile  excitement,  is  not 
produced. 

Thus,  an  inflammation  of  the  skin,  cellular 
tissue  fee.,  docs  not.  produce  fever  so  readily  as 
inflammation  of  the  parenchyma  of  the  lungs,  of 
the  pleura,  or  of  the  synovial  membranes. 

4.  When  it  occurs  in  persons  whose  constitu- 
tions are  neither  above  the  standard  of  health,  nor 
below — neither  plethoriq  nor  ancemic — ,  fever  is  not 
readily  produced. 

( ircumstances  u,nderwliich  Ferry  is  readily  produced. 

1.  When  the  Inflammatory  process  assumes  a 
greater  degree  of  violence  than  is  necessary  for  the 
repair  of  tissues,  and  threatens  the  disorganization 
of  the  part. 

2.  When  it  involves  a  considerable  portion  of 
the  animal  structures. 

!!.  When  it  affects  tissues  which  possess  a  high 
degree  of  Organization.  Instances  in  explanation 
of  this  point  were  given  under  the  last  head, 
though  if  additional  proof  be  wanting,  reference 
can  be  made  to  the  facility  with  which  Fever  is 
developed  in  connexion  with  Inflammation  of  the 
delicate  coat-  of  the  eve,  of  the  nerves  and  of  the 
internal  tunics  of  the  blood  vessels. 

4.  When  it  attacks  parts  which  have,  numerous 
and  important  nervous  connexions  with  the  system 
al  large.  In  this  way  fever  is  developed  either 
directly,  or  indirectly  by  what  is  known  as  nervous 
reflex  action.  Thus  [nflammatioria  of  the  brain 
spinal  cord,  and  stomach  readily  and  rapidly  pro- 
duce an  impression  upon  the  whole  system,  which 
expresses  itself  in  fehrile-exoitmeat 


26  SYMPTOMS. 

5.  When  it  occurs  in  persons  whose  constitu- 
tions possess  an  unusual  degree  of  susceptibility  to 
local  impressions  and  general  influences  of  a 
morbid  character. 

6.  When  it  is  developed  in  those  whose  nervous 
systems  are  particularly  irritable  because  of  the 
existence  of  plethora,  or  of  ancemia,  though  in  the 
one  instance  the  fever  assumes  a  sthenic  character 
whilst  in  the  other,  it  is  of  a  low  grade. 

7.  When  it  exists  in  connexion  with  an  epide- 
mic of  fever,  the  development  of  malarial  poison, 
or  those  debilitating  influences  which  are  the  pro- 
lific sources  of  typhoids,  and  typhus,  such  as  infest 
crowded  camps,  ill-ventilated  Hospitals,  and  the 
confined  Burden  Cars  in  which  soldiers  are  so  fre- 
quently transported. 

Definition  of  Fever.  -Lt  is  a  matter  of  the  first 
importance  to  understand  the  exact  meaning  of 
the  word  Fever,  to  comprehend  the  precise  pa- 
thological conditions  which  are  included  in  and 
expressed  by  that  most  significant  term. 

From  the  days  of  Celsusto  the  present  time,  the 
Profession  has  sought  eagerly  tor  a  proper  defini- 
tion of  Fever;  but  it  is  generally  agreed,  that  Cul- 
lin's  description  embodies  the  most  correct  en  umer- 
ation  of  its  essential  phenomena.  It  is  as  follows  : 
"  after  a  preliminary  stage  of  languor,  weakness, 
and  defective  appetite,  there  occur  acceleration  of 
the  pulse,  increased  heat,  great  debility  of  the 
limbs,  and  disturbance  of  most  of  the  functions, 
without  primary  local  disease." 

Phenomena  of  Fever. — EssentialP  henomena. — 
Galen  long  since  declared  that  the  essence  of  fever 


kfPTOM  •  27 

consists   in  a  color  prceter  naturam,  and   the  most 
recondite  researches  and   scientific   analyses  have 
succeeded  in  discovering  no  element  thai  is  more 
characteristic,    constant  and  important   than   the 
vation  of  tranperahm    which   invariably   accom- 
panies the  febrile  paroxysm.     That    there    is  such 
an  elevation  has  been  decided  by  the  experiments 
of'De  ffaen,  who  found,  that  even   in   the  algid 
here  was,  in   the  internal  parts,   a 
manifest  increase  of  temperature,  in  some  cases  to 
the   extenl  of  2  .,  3'    and  even    1  ',  and  that  the 
slightest  febrile  conditions  are    attended    with  an 
increase    of  heat,  which    is  likewise  in  some  in- 
te   only  observable    phenomenon  what- 
ever. 

The  chief  source  of  the  increased  tempera- 
ture in  Fever  is  to  be  sought  in  an  exaggeration 
of  those  causes  which  operate  in  the  production  of 
heat  in  the  normal  stale  of  the  system.  It  is  now 
universally  admitted,  that  the  source  of  the  normal 
temperature  is  to  be  found  in  the  chemical  de- 
velopment of  heat,  which  results  from  the  nutrient 
processes  invariably  occurring  in  the  various 
structures  of  the  organism.  It  follows  therefore, 
that  th<  '.of  tern  which  characterizes 

the  febrile  condition,  is  the  result  and  the  exponent  of 
'Hi  ■  d  metamorplwsis in  tf  .     It   must 

1)'-  remarked,  in  this  connexion,  that  there  is  not 
"ids    an    increased  nption   *A'   the   natural 

pabulum  which  the  blood  supplies  to  tissues,  but 
that  the  actual  constituent  elements  of  the.  body 
themselves  are  appropriated  and  removed  by  the 
increased    metamorphic   activity    indued  in   the 


28  SYMPTOMS. 

structures  generally.  Thus  the  fluids,  the  muscles, 
the  adipose  tissue,  the  glands  and  even  the  bones 
themselves  waste  away  during  the  progress  of  a 
febrile  attack,  particularly  if  it  be  of  long  duration, 
or  of  great  intensity. 

As  the  normal  nutrition  of  the  tissues  bears 
a  direct  ratio  to  the  amount  of  blood  distributed 
to  them, — since  it  is  the  source  of  their  pabulum, 
it  follows  that  the  accelerated  metamorphosis 
which  characterizes  the  Febrile  paroxysm,  must  be 
accompanied  by  an  increased  activity  of  the  circu- 
lation. It  is  well  known  that  however  induced, 
an  augmentation  of  the  force  and  the  rapidity  of 
the  circulation  presents  itself  among  the  earliest 
concomitants  of  a  large  majority  of  febrile  at- 
tacks. So  invariable  is  this  association,  in  fact, 
that  alterations  in  the  Pulse  are  universally  re- 
garded as  an  essential  element  of  that  peculiar 
condition  which  we  denominate  fever. 

Metamorphosis,  though  depending  to  a  great 
degree  upon  the  amount  of  pabulum  supplied  by 
an  increased  .circulation,  or  an  accumulation  of 
blood  from  any  cause,  is  also,  to  a  certain  extent, 
influenced  and  controlled  by  the  nervous  system, 
since,  as  before  remarked,  it  has  the  power  of  in- 
creasing the  appetite  of  the  ultimate  elements,  and 
of  thus  inducing  a  larger  consumption  of  those 
materials  upon  which  they  feed. 

It  has  been  shown  by  Bernard,  Sequard, — 
Weber,  Virchow  and  others,  that  the  nervous 
system  exercises  a  direct  and  most  potent  control 
over  the  circulation.  Thus,  Bernard  has  demon- 
strated that  the  section  of  the  sympathetic  nerve 


SYMPTOM.-.  29 

in  the  neck  is  followed  by  a  rapid  increase  of  tem- 
perature in  the  corresponding  side.  Brown  Se- 
quard  has  cut  the  sympathetic  filaments  dis- 
tributed to  the  oar  of  a  Rabbit,  and  found,  that 
there  was  not  only  an  increase  o\'  temperature  in 
it,  but  that  the  blood  was  Avarmcr  on  leaving,  than 
when  it  entered  the  part.  Weber  lias  shown,  that 
irritation  of  the  Vagi  nerves  causes  an  arrest  of  the 
heart's  action;  and  it  has  been  known  for  a  long 
period,  that  after  section  of  these  nerves,  an  im- 
mediate and  decided  acceleration  of  the  pulse  takes 
place.  Similar  experiments  have  been  made  by 
Ludwig,  Valkman,  Fowelin,  and  Traube,  and  with 
like  results  ;  whilst  Virchow  has  investigated  the. 
subject  still  farther,  and  with  such  success  as  to 
induce  him  to  build  upon  the  facts  eliminated,  the 
whole  superstructure  of  his  febrile  pathology. 
For  these  reasons,  it  is  now  regarded  as  an  es- 
tablished fact,  that  certain  parts  of  the  nervous 
system  preside  over  the  general  and  local  circula- 
tions, and  that  all  changes  in  them,  depend  upon 
andrepresentcertain  complimentary  and  precedent 
alterations  in  the  nervous  status  of  the  organism. 
Virchow,  who  may  be  regarded  as  the  great 
pathological  pioneer  ot  the  19th  century,  believes 
that  these  alterations  affect  primarily  the  regulator 
or  moderator  functions  of  the  nerves,  and  that  the 
nerves  which  play  this  important  part  in  the 
economy  are  the  Vagi  and  Sympathetic,  having, 
in  all  probability,  their  centre,  especially  the 
former,  in  the  Medulla  Oblongata. 


30  SYMPTOMS. 

The  essential  phenomena  of  Fever  may  therefore 
be  thus  summed  up : 

1.  Increased  heat,  produced  by — 

2.  Increased  metamorphosis,  produced  by — 

3.  Acceleration  of  circulation,  produced  by — 

4.  An  irritation  of  the  regulator  nerves,  especial- 
ly the  Sympathetic  and  Vagi,  whose  centres  are  in 

the  Medulla  Oblongata. 

Non  essential  phenomena  of  Fever. — Fever 
may  be  accompanied  by  pain  especially  of  the 
the  head  and  loins  ;  a  sense  of  heaviness  or  general 
lassitude ;  deficiency  of  either  secretion,  or  of  all  of 
them;  dryness  of  skin;  thirst;  nansia;  scanty  and 
high  colored  urine;  delirium;  constipation;  jactation ; 
&c.  Some  one  of  these  symptoms  is  always  present 
in  connexion  with  inflammatory  action,  but  they 
constantly  vary,  and,  on  that  account  may  be  re- 
garded as  non  essential  phenomena. 

Varieties  of  Fever. — Fevers  may  be  divided, 
with  reference  to  the  causes  producing  them,  into 
two  great  varieties,  viz :  Idiopathic  and  Symptomatic. 

1.  Idiopathic  Fevers. — These  are  produced 
by  causes  of  an  inappreciable  character,  either 
developed  within  or  without  the  organism,  and  act- 
ing upon  the  nervous  system  directly  or  indirectly 
through  the  agency  of  the  blood.  Typhoid,  and 
Typhus  are  types  of  this  class  of  Fever. 

2.  Symptomatic  Fevers  are  produced  by  some 
injury  or  disease  of  a  particular  portion  of  the 
organism.  They  are,  in  fact,  nothing  more  or  less 
than  the  system's  response  to  an  impression  made 
by  a  disturbing  agency,  upon  some  one  of  its 
parts —  the  general    manifestation    of   a  special 


SYMPTOMS.  31 

pathological  disturbance.    It  is  with  Fevers  of  tin 
discription  that  the  Surgeon  lias  specially  to  deal, 
and  the}-  must  therefore  lie  particularly  considered 
in  this  connexion. 

The  essential  elements  ot'al I  feversare  identical, 
while  their  non-essential  phenomena  constantly  va- 
ry. Heat:  in  ceased  metamorphosis;  acceleration  of 
the  circulation;  and  nervous  disturbance  are  the  in- 
variable phenomena  which  distinguish  and  charac- 
terize febrile  action.  Fever,  then ,  regarded  as  a  pa- 
thological entity— a  distinct  unit,  made  up  of  the 
peculiar  morbid  conditions  just  mentioned — is 
always  the  same  so  far  as  its  essential  nature  is 
concerned.  It  is  true  that  the  degree  of  heat,  the 
extent  of  the  metamorphosis,  the  rapidity  of  the 
circulation,  and  the  amount  of  nervous  disturbance 
arc  exceedingly  variable;  but  it  is  equally  certain 
that  the  mode,  order  and  history  of  their  develop- 
ment are.  precisely  the  same  under  every  variety 
of  circumstances.  Tt  is  therefore  a  misnomer  to 
denominate  fever  per  se  as  inflammatory,  irritative, 
&c.  j  and,  hence,  Hie  usual  classification  adopted 
by  writers  on  this  subject,  is  manifestly  unphiloso- 
phical  because  it  has  no  foundation  in  positive 
pathological  fact. 

Fever,  however,  may  associate  itself  with  the  In- 
flammation ofa  healthy  system,  orwith  the  [nflam- 
mation  of  a  debilitated,  impoverished    each" 
system. 

The  first    is  known    ns    Pyrexia,    or   true  Sur- 
gical   fev<  r.  and  character.      Jt> 
symptom    are  a   li"t  and   dry  skin;  a  full,  bound 
ing  and  frequent  pulse;  the  diminution  or  a 


32  ,  SYMPTOMS. 

the  secretions;  acidity  and  high  color  of  the  urine; 
constipation  of  the  bowels;  coating  of  the  tongue 
with  a  white  fur;  thirst;  languor.,  heat  and  pain 
of  head.  A  disposition  is  always  manifested  in 
this  connexion,  to  remit  or  intermit,  or  in  other 
words,  the  fever  is  not  of  a  continuous  character. 

Its  abatement  is  followed  hy  the  subsidence  of  all 
the  symptoms  mentioned  above: — by  a  free  per- 
spiration;— by  abundant  discharge  of  urine  a- 
bounding  in  Uthates ; — by  a  natural  movement  of 
the  bowels,  or  it  maybe  diarrhoea; — by  cleansing 
of  the  tongue,  abatement  in  the  frequency  and 
force  of  the  pulse  ; — by  subsidence  of  thirst  and  a 
general  feeling  of  relief  on  the  part  of  the  patient. 

The  second  which  is  of  a  decided  asthenic  charac- 
ter, presents  itself  under  three  forms,  viz:  Typhoid 
Fever, Irritative  or  Nervous  Fever,  and  Hectic  Fever. 

The  true  Asthenic  or  Typhoid  Fever  occurs  prin- 
cipally in  persons  whose  constitutions  are  enervated 
by  exposure,  privation,  irregularity,  of  life,  grief, 
or  long  residence  in  a  vitiated  atmosphere. 

Symptoms. — The  period  of  depression  is  marked 
and  much  prolonged.  The  reaction  is  not  of  a 
very  active  character ;  there  is  a  disposition  to 
heaviness,  stupor,  and  delirium  ;  the  pulse  is  feeble 
but  quick  and  frequent;  the  skin  is  sometimes 
moderately  hot,  then  again  is  particularly  dry  and 
burning,  and  occasionally  covered  with  an  abundant 
perspiration  ;  the  cheeks  are  flushed,  and  the  eye< 
bright  and  starring,  while  the  tongue  is  red,  dry 
and  sometimes  cracked  in  its  centre. 

The  abatement  of  the  fever  is  characterized  by  a 
gradual  disappearance  of  all   the   symptoms  ; 


BfMPTOMS  33 

the   patient   remains   weak    and    debilitated    for 
nd  the   return   to   health   is   invariably 
alow  and  uncertain. 

Should  the  disease  lake  an  unfavorable  turn,  the 
pulse  grows  more  feebleand  frequent,  the  tongue 
dryer  and  more  cracked,  the  skin  eoWand  mottled  ; 
while  hiccup,  subsultus,  dyspnoea  or  coma  comes  on 
and  death  closes  the  scene  by  claiming  its  victim. 
There  is  always  a  tendency  to  visceral  compli- 
cations in  connexion  with  this  affection,  which 
not  unfrequently  decide  the  fate  of  the  pa- 
tient. The  fever  is  usually  continuous  and  pa- 
thologists locate  the  especial  seat  of  the  disease  in 
the  Sympathetic  system. 

Irritative  Fever  is  a  variety  of  the  asthenic  form 

though  not  of  so  specific  a  tyj>e   as  the  last.     The 

rvous  system  is  especially  concerned  ;   and   the 

,  action   presents   itself  in   connexion   with   the 

those  whoso  mental  powers    have  been 

over  taxed,  or   whose   vital  energies   have  been 

destroyed  by  excessive  venery,  indulgence  in  drink. 

ul  intellectual  Labor,  &c. 

The  symptoms  which  distinguish  Irritative  fever 

areadry  and  red  tongue;  a  sharp,  small,  but  frequ- 

entpulse;  subsi  and  delirium,  which 

rive  place  to  sigus  of  debility,  with  coma  and 

rebral   irritation,  sudden    exacerbations,  unequal 

and    irregular   remissions;    rapid    and   important 

iqueut  concomitauts  of  this  form 

of  disease. 

Bectic  Fever,  is  also  a  variety  o{  the  asthenia  form 

and  generally  present*  iUelf  in  conjunctiou    with 

►rganic,  ieriousdi  ive  dischargeol 


34  TERMINATIONS. 

any  secretion,  but  more  particularly  with  the  for* 
mation  of  abcesses  and  the  production  of  pus. 
Emaciation;  debilit}7;  clear  and  red  tongue? 
disposition  to  diarrhoea  and  profuse  perspiration; 
a  frequent  and  small  pulse;  slight  chills  follow- 
ed by  burning  of  the  hands  and  feet,  with  a  cir- 
cumscribed flush  upon  the  cheek,  indicating  de- 
rangement of  the  capillary  circulation,  are  the 
symptoms  which  characterize  this  form  of  fever. 

Hectic  is  but  too  frequently  the  harbinger  of  a 
speedy  death  ;  and  yet,  it  is  really  astonishing  to 
observe  with  what  rapidity  and  completeness 
many  patients  recover  even  after  the  development 
of  its  most  characteristic  and  unfavorable  symp- 
tomps. 

It  not  unfrequently  has  the  effect  also  of  pro- 
ducing an  exhileration  of  the  spirits, — elevating 
them  to  such  an  extent  as  to  preclude  all  fear  of 
the  fatal  catastrophy  of  which  it  is  the  sad  pre- 
cursor. 

Terminations  of  Inflammation. — Inflamma- 
tion may  terminate  either  in  the  repair  of  the 
part;  in  its  return  to  health  ;  in  the  modification  of 
its  function  and  struct  arc;  or  in  its  death. 

Repair  of  the  part. — A  part  whose  continuity 
has  been  broken  or  destroyed  may  be  repaired, 
after  the  development  of  ruflammation,  either  by 
the  immediate  organization  of  the  Effused  Lymph, 
or  by  its  more  slow  and  gradual  conversion  into 
a  structure  identical  with  that  of  the  subjacent 
tissues  or  similar  to  it. 

When  the  repair  is  immediate,  it  is  called  union 
by  the  "  First  Intention,"  and  when  more  tardy  — 


TERMINATION-  o5 

being  accompanied  by  the  formation  of  healthy 
pus,  granulation,  &c„,  it  is  denominated  union  by 
the  "  Second  Intention." 

Restoration  of  the  Part  to  health. — Inflammation 
may  be  developed  in  a  part,  which  has  suffered  no 
solution  of  continuity,  under  the  influence  either 
of  some  Loeal  or  General  cause,  and,  after  the 
manifestation  of  all  the  characteristic  symptoms, 
of  that  process,  leave  it  in  its  original  condition. 
This  is  accomplished  by  the  reabsorption  of  the 
effused  Plasma,  either  in  its  nascent  stale,  <>r  after 
it  has  been  changed  into  blastema  and  fibro-cellu- 
lar  tissue.  The  absorption  of  the  Lymph  in  its 
liquid  state  is  denominated  Resolution,  and  is  the 
most  favorable  termination  or  effect  of  Inflamma- 
tion. Nature,  in  many  cases,  labors  to  make  way 
with  effused  Lymph  in  such  a  manner  as  will  prove 
least  injurious  to  the  surrounding  parts  as  well  as 
to  the  organism  ;  and,  hence,  the  work  of  reab- 
sorption is  commenced,  under  its  watchful  and  in- 
telligent guidance,  to  be  perfected  or  not  accor- 
ding to  the  circumstances  of  the  ease.  Each 
petholigical  step  is  then  carefully  and  successfully 
retraced.  The  attraction  between  the  Q-lohules 
and  the  walls  of  the  vessel,  loses  its  intensity  ;  the 
stasis  of  Blood  disappears;  the  Heat,  Pain  and 
Swelling  abate;  and  the  part  assumes  its  normal 
status,  both  as  regards  function  and  organization. 
Et  sometimes  happens,  however,  that  all  of  these 
steps  are  taken  suddenly  and  simultaneously,  or 
occur, so  rapidly  as  to  be  inappreciable.  This  is 
i  \  led  DeUtesa  n 
Metastasis  is  the  sudden  translation  of  Intiainma- 


35  TERMINATIONS. 

tion  from  one  "point  to  another.  This,  in  a  ma- 
jority of  cases,  may  be  regarded  as  a  phenomenon 
of  Nervous  Reflex  Action — a  principle  which  plays 
a  most  important  role  both  in  the  Physiological 
and  Pathological  processes  of  the  organism. 

Resolution  is  the  natural,  legitimate  and  most 
favorable  conclusion  of  the  Inflammatory  process — 
a  result  towards  which  the  efforts  of  the  Practi- 
tioner should  be  invariably  directed  as  the  most 
effectual  method  of  preventing  disastrous  conse- 
quences. 

The  Absorption  of  Lymph  after  its  conversion 
into  blastema  and  fibro- cellular  tissue,  does  not 
occur  to  any  considerable  extent  during  the  height 
of  the  inflammation  by  which  it  has  been  produ- 
ced. There  must  always  be  a  marked  reduction 
of  the  morbid  action  before  the  absorbent  vessels 
can  be  forced  to  take  hold  of  it ;  but  when  this 
point  has  been  once  reached  the  process  often  goes 
on  with  great  rapidity.  When  the  Lymph  has 
become  completely  organized,  absorption  is,  of 
course,  still  more  difficult,  and  not  unfrequently 
impossible. 

It  is  more  than  probable  that  Lymph  even  in  a 
liquid  state,  is  not  absorbed  until  it  has  been  dis- 
solved in  the  fluids  of  the  affected  parts,  when  it  is 
brought  more  readily  under  the  influence  of  the 
absorbent  vessels. 

Modification  of  the  structure  and  functions  of  the 
Part.  Inflammation  may  also  leave  the  Part  mod- 
ified both  as  regards  function  and  structure.  This 
modification  is  due  to  the  influence  of  certain  pro- 
ducts* oi  the  Inflammatory  Process,  which  should 


TERMINATIONS.  37 

be  briefly  considered,  in  connexion  with  this  mode 
of  development,  and  the  nature  of  the  effects  pro- 
duced by  them. 

The  effects  or  products  of  Inflammatory  Action, 
which  play  this  important  part  in  the  economy 
are :  Induration,  Hypertrophy,  Atrophy,  Effusion 
of  Serum,  Formation  of  Pus,  Organization  of  the 
effused  Lymph,  or  Transformation  of  Tissue. 

Induration.  When  the  effused  lymph  is  not 
absorbed  it  organizes,  either  forming  a  sort  of  in- 
ternal cicatrix  which  is  harder  than  the  surrounding 
tissues  or  increasing  the  density  of  the  part  by  aug- 
menting the  amount  of  plastic  material  within  it. 

Softening.  This  results  either  from  the  infiltra- 
tion of  effused  liquids,  or  disintegration  of  the 
substance  of  the  textures  themselves,  by  which 
their  consistence  is  diminished. 

Hypertrophy.  It  has  been  previously  shown 
that  the  Inflammatory  Process  not  only  increases 
the  amount  of  Blood — the  pabulum  sent  to  a  given 
tissue — but  also  stimulates  the  appetite  of  the  part, 
so  as  to  render  its  nutrition  more  active  and  com- 
plete. It  thus  happens,  not  unfrequently,  that 
tissues,  and  whole  organs  are  permanently  enlarg- 
ed, asa  consequence  of  Inflammation. — Hypertro- 
phy is  essentially  a  local  disease. 

Atrophy.  Though  atrophy  is  the  opposite  of 
Hypertrophy  it  is  not  an  unusal  effect  of  Inflamma- 
tion. Nutrition  is  made  up  of  two  elements,  which 
though  entirely  distinct,  the  one  from  the  other, 
are  absolutely  essential  to  the  perfection  of  the 
process.  Cell  destruction  as  well  as  Cell  elabora- 
tion—the breaking  down  and  the  building  up  of 


38  TERMINATIONS. 

;,  occur  simultainously  throughout  the  whole 
organism.  The  term  metamorphosis  includes 
both  of  these  processes  ;  and  in  the  normal  condi- 
tion of  the  system  presupposes  a  perfect  equili- 
brium between  them.  Under  the  influence  of  In- 
flammation this  equilibrium  is  lost,  so  that 
cells  may  be  too  readily  produced,  or  too  rapidly 
destroyed.  In  the  one  instance  Hypertrophy  is 
produced  and  in   the   other  Atrophy  is  the  result. 

Effusion  of  Serum. — Congestion  or  the  accu- 
mulation of  Blood  in  the  part  affected,  consti- 
tutes one  of  the  distinguishing  features  of  Inflam- 
mation. It  is,  in  fact,  an  essential  element  of  that 
process.  The  vessels  thus  become  filled  with  an 
unusual  quantity  of  the  circulatory  fluid,  which 
distends  their  coats,  and  «facilitates  the  pouring 
out,  or  the  exosmosis  of  the  watery  portion  of  the 
Blood  into  subjacent  cavities  or  neighbouring 
tissues.  It  is  in  this  way  that  fluxes  are  produced 
and  dropsies  occur,  materially  altering  the  struc- 
ture of  tissues  and  organs,  and  interfering  with 
their  peculiar  functions.  All  the  tissues  do  not 
present  the  same  tendency  to  the  effusion  of  serum 
in  connexion  with  Inflammatory  action.  The 
structures  which  supply  it  in  greatest  abundance 
are  the  cellular  and  serous,  the  secernent  vessels  of 
which  are  extremely  active  even  when  the  disease 
itself  is  comparatively  mild.  The  mucous  mem- 
brane of  the  alimentary  canal,  particularly  that  of 
the  Colon  and  Rectum  is  frequently  the  source  of 
large  effusions  of  serum,  as  is  seen  in  diarrhoea 
and  Cholera  Infantum. 

The  appearance  of  the  serum  is  usually  limpid, 


TERMINATIONS.  39 

though  it  may  be  changed  by  admixture  with  the 
secretions,  Lymph  or  Pus.  The  effusion  of  Serum 
is  always  a  phenomenon  of  Osmosis,  while  it  is  con- 
trolled by  the  laws  which  govern  that  process, 
and  is  dependent  upon  that  principle  alike  for  its 
production  and  its  cure. 

Suppuration  or  the  formation  of  Pus.  The 
idea  was  long  entertained  that  Pus  was  a  veritable 
secretion,  poured  out  from  the  vessels  under  cer- 
tain abnormal  circumstances,  and  subject  to  all 
the  laws  which  control  the  products  of  secerning 
organs  general ly.  The  researches  and  arguments 
or  Gulliver,  Mandt  and  Addison  have  demonstra- 
ted the  incorrectness  of  this  opinion  ;  and  it  is  now 
generally  agreed  among  Pathologists,  that  Tus 
Corpuscles  are  modifications  of  the  Exudation  Cells, 
and  that  suppuration  is  nothing  more  nor  less 
than  the  breaking  down  or  degeneration  of  the 
Lymph  poured  out  in  connexion  with  the  inflam- 
matory  process. 

When  Lymph  is  not  converted  into  tissue,  or 
false  membranes — because  of  the  blight  impressed 
upon  the  formative  power  of  the  contiguous  struc- 
tures by  the  Inflammatory  action — or  fails  to  or- 
ganize even  into  cacoplastic  products,  a  peculiar 
depreciation  takes  place  in  it  whereby  the  corpus-' 
cles  of  the  Plastic  mass  are  transformed  into  Pus 
Cells,  the  Blastema  degenerates  into  liquor  puris, 
and  Purulent  matter  takes  the  place  of  the  more 
highly  organized  effusion. 

When  Pus  is  formed  upon  a  free  surface,  it  is 
styled  a  Purulent  secretion;  and  when  elaborated 
within  the  structure  of  a  part,  it  is  called  an  Abscess. 


40  TERMINATIONS. 

Nature  usually  makes  an  effort  to  retain  the  Pus 
thus  formed  within  limited  bounds,  by  depositing 
around  it  an  external  boundary  of  consolidated 
Lymph,  known  as  the  Pyogenic  Membrane.  This 
does  not  secrete  Pus  as  was  supposed  by  Delpech 
and  many  others,  but  is  simply  the  boundary  line 
between  the  abnormal  product  and  the  intact 
tissues.  When  this  Membrane  is  absent,  it  may 
be  regarded  as  indicative  of  a  want  of  tone  in  the 
system,  and  as  such  furnishes  a  valuable  hint  to  the 
Surgeon  as  regards  prognosis  and  treatment.  In 
the  above  remarks  concerning  this  Pyogenic  Mem- 
brane, the  production  of  Pus  in  connexion  with 
abscesses,  is  only  referred  to.  This  fluid  is  elabo- 
rated aloug  the  track  of  wounds  extending  through 
tissues  of  all  grades  and  varieties,  with  so  much 
rapidity  and  in  such  large  quanties,  as  to  preclude, 
even  in  the  most  vigorous  constitutions,  the  for- 
mation of  a  protecting  membrane,  and  is,  hence, 
found  diffused,  in  many  instances,  throughout  the 
subjacent  structures. 

When  Pus  is  opaque,  thick,  smooth,  slightly 
glutinous,  of  a  yellowish  white  color,  with  a  green- 
ish tiuge,  a  faint  odour  and  a  alkaline  reaction, 
it  is  said  to  be  healthy  or  laudable ;  when  mixed 
and  tinged  with  blood  it  is  sanious ;  when  thin 
watery  and  acrid,  ichorous  ;  when  it  contains  cheesy 
looking  flakes,  curdy,  and  when  diluted  with 
mucus  or  serum,  muco-pus  or  suto-jms. 

It  consists,  when  laudable,  of  corpuscles,  floating 
in  a  homogeneous  fluid,  styled  "  liquor  puris." 
These  corpuscles  are  modifications  of  the  exuda- 
tion-cells, and  are  composed  of  a  semi-transparent 


TERMINATIONS.  41 

cell-wall,  with  two  or  three  nuclei,  of  large  quan- 
tities of  granular  matter.,  of  particles  of  fibrin, 
and  of  disintegrated  exudation  cells.  A  multi- 
tude of  changes,  however,  may  occur  in  it,  altering 
its  composition,  and  changing  its  character,  which 
can  be  detected  by  the  microscope.  When  the 
suppurative  process  has  once  been  set  up,  it  may 
continue  for  an  indefinite  period,  becoming,  as  it 
were,  the  fixed  secretion  of  the  part.  From  mucous 
membranes  particularly,  it  has  been  known  to 
last  for  years. 

The  symptoms  which  indicate  that  Pus  is  about 
to  be  formed,  are ;  a  more  throbbing  pain,  a  greater 
swelling  and  tension  of  the  part,  and  a  red,  glazed 
and  shining  appearance  of  the  skin,  though  it  is 
sometimes  elaborated  without  the  development  of 
any  antecedent  local  sign. 

The  symptoms  which  indicate  that  Pus  has  been 
formed  are :  the  disappearance  of  the  ordinary 
signs  of  inflammation  ;  the  occurrence  of  chills  or 
rigors  ;  alternations  of  heat  and  cold;  abatement 
of  the  intensity  of  the  fever,  and  its  assumption, 
in  some  instances,  of  an  intermittent  character; 
softening  and  perhaps  qnickening  of  the  pulse  ; 
and  fluctuation  in  the  part,  with  enlargement 
also  when  the  fluid  is  diffused  throughout  its 
tissues. 

The  symptoms  which  indicate  that  Pus  is  esca- 
ping from  the  system  in  too  great  a  quantity,  arc  : 
emaciation  and  loss  of  strength,  a  quick,  small 
and  compressible  pulse  ;  a  coated  and  dry  tongue 
with  red  tips  and  edges;  flushed  cheeks;  dilated 
pupils;  profuse  sweating;  copious  purging;  large 


42  TERMINATIONS. 

discharges  of  urine,  filled  with  red  deposits ;  great 
debility ;  hypocratic  countenance  ;  husky  voice  ; 
insomnia,  &c.  There  is  usually  an  exacerbation 
towards  evening,  and  the  actions  upon  the  bowels, 
skin  and  kidue}^s  alternate  with  each  other,  until 
the  patient  dies  from  sheer  exhaustion. 

The  tendency  to  suppuration  is  increased  by  the 
following  circumstances,  viz : 

1.  Peculiar  conditions  of  the  Patient's  system. 
Thus,  in  conditions  of  debility  from  any  cause 
which  diminishes  the  vital  powers,  as  bad  food, 
impure  air,  cachectic  states  of  the  organism,  scro- 
fula, &c. 

2.  Specific  character  of  the  Inflammatory  pro- 
cess. Thus,  in  Gonorrhoea  and  Purulent  Opthal- 
mia,  Pus  is  more  readily  eliminated  than  under 
ordinary  circumstances. 

3.  Locality  of  the  Inflammation.  Mucous  mem- 
branes more  readily  suppurate  than  serons,  &c; 
cellular  tissues  more  rapidly  than  muscular,  &c. ; 
Iuflammatory  surfaces  when  exposed  to  atmos- 
pheric air  supurate  more  readily  and  freely  than 
others. 

4.  The  state  of  the  part  affected.  All  parts  of 
the  system  are  not  invariably  in  the  same  condition 
of  health.  Thus  the  nerves  running  to  a  particu- 
lar part  may  have  been  divided  by  some  previous 
accident,  or  some  affection  peculiar  or  confined  to  it 
may  have  lowered  the  tone  of  its  vital  powers,  &c. 
In  this  way  Inflammations  which  some  portions 
of  the  body  would  readily  resist,  terminate  else- 
where in  suppuration. 

The  Plastic  matter  thus  destroyed  is  the  food  of 


TERMINATIONS. 


the  tissues  involved  in  the  Infla  on— 

the  pabulum  upon  which  they  depend  for  the  pre- 
servation of  such  properties  as  arc  essential  to  the 
integrity  of  their  structure  and  the  perfection  of 
their  functions. 

Again,  the  purulent  fluid  by  desseminating 
itself  throughout  the  tissues,  or  by  pressing  upon 
them,  so  changes  the  normal  status  of  the.  part  as 
to  disqualify  it,  cither  partially  or  completely,  for 
the  performance  of  its  proper  offices. 

Of  the  fatal  consequences  which  connect  them- 
selves with  the  presence  of  Pus  in  the  blood,  it  is 
unnecessary  to  speak  in  detail  here,  in  as  much  as 
they  will  be  more  fully  discussed  in  another  con- 
nexion. It  is  sufficient  to  say  that  the  Purulent 
elements,  when  thus  absorbed  or  developed,  so 
paralyze  the  nervous  centres  and  blight  the  tissues 
of  the  organs  generally,  as  to  interfere  with  the 
action  of  all  the  component  parts  of  the  organism — 
suspending  nutrition,  aborting  or  altering  secre- 
tion, robbing  the  muscles  of  their  tone  and  power, 
destroying  "nervous  influence,"  and  inducing  a 
complete  revolution  in  the  whole  system. 

Organization.  The  Plastic  Lymph  effused  in 
connexion  with  the  Inflammatory  process  may 
cither  Organize  or  breaJc  down  into  Pus.  The  term 
organization  includes  the  n  of  the 

into  tissue,  taking  racter  from  the  subj; 

structures;  the  development  of  fals 
and  the   formation  ■  in  hcteromorphou 

ducts,  as    Tubercle,  I  Plastic  Lymph 

an   inhere!)  iity  for  organization, 

oon  as  ii  is  effused,  this  tendency   mai 


44  TERMINATIONS. 

itself  by  the  formation  of  cells  and  nuclei  in  great 
numbers,  which  connect  themselves  with  each 
other,  and  gradually  spread  out  into  fibres  lying 
for  the  most  part  in  parallel  lines,  and  profusely  in- 
laid with  granules.  Vessels  soon  show  themselves, 
which  are  the  result  either  of  a  new  epigenesis,  or 
the  contributions  of  the  neighboring  structures, 
the  latter  being  the  more  common  source  of  sup- 
ply. Nerves  and  absorbents,  finally  appear,  but 
whether  they  are  supplied  by  the  surrounding 
tissues,  or  are  spontaneously  developed  from  the 
effused  matter,  has  not  been  determined  by  Pa- 
thologists. In  this  manner  the  effused  Lymph 
either  assumes  the  characters  and  functions  of  the 
tissues  with  which  it  is  in  contact,  or  forms  false 
membranes.  "When,  however,  there  is  a  deficiency 
of  nervous  influence  in  the  part  or  system,  a  want 
of  plasticity  in  the  effusion  itself,  or  a  deficiency 
of  vital  power  in  contiguous  tissues,  the  same  at- 
tempt at  organization  is  made,  but  the  issue  is  an 
aborption,  and  a  product  results,  of  an  inferior  de- 
gree of  organization,  and  lower  in  the  scale  of 
vital  endowment,  to  which  the  term  heteromorphus 
has  been  applied.  It  is  m  this  way  that  Tubercle 
and  other  similar  growths  are  developed,  as  the 
effects  of  Inflammation,  complicating  the  termina- 
tion of  that  process,  and  inducing  eventually  the 
most  serious  consequences  to  the  system. 

Inflammation  may  terminate,  leaving  behind  the 
liigher  products  thus  formed  in  a  state  of  complete 
organization,  and  materially  modifying  the  structure 
and  functions  of  the  part  in  which  they  have  been 
developed.     An  organ,  as  the  Liver  or  Spleen, 


TERMINATIONS.  45 

tvhich  has  been  hypertrophied,  by  the  organization 
of  Lymph  cftused  into  its  structure,  does  not  pre- 
serve its  original  statics  either  physically  or  func- 
tionally, and  is,  hence,  modified  to  an  appreciable 
extent  by  the  precedent  morbid  action.  iSo  like- 
wise, False  Membranes,  by  agglutinating  the  Intes- 
tines, binding  together  the  Costal  and  Pulmonary 
Pleura,  constricting  or  contracting  the  Urethra, 
&c.,  &c.,  materially  interfere  with  the  legitimate 
functions  of  these  parts,  and  produce  disastrous 
consequences  in  the  economy. 

Transformation  of  Tissues.  Each  tissue  posses 
the  power  of  appropriating  certain  elements  suppli- 
ed by  the  Blood,  and  of  converting  them  into  its 
own  substance.  In  order  that  this  " formative 
'power'"  may  be  legitimate!)  exercised,  it  is  neces- 
sary that  the  structures  remain  in  a  condition  ot 
health,  that  the  ordinary  supply  of  nervous  influ- 
ence and  of  proper  pabulum  be  supplied  them, 
and  that  their  normal  Ph}-siological  status  continue 
intact.  The  Inflammatory  Process  interferes  with 
the  supply  of  nervous  influence,  and  destroys  the 
responsive  power  of  the  tissues  without  necessarily 
depriving  them  of  the  elements  which  constitute 
their  proper  food.  Instead  of  converting  plastic 
Lymph  into  their  own  substance,  they  simply 
impress  it  with  a  sufficiency  of  vital  force  to 
insure  Its  organization  into  tissues  of  a  lower 
grade,  and,  hence  a  spcies  of  degenerati<mtov  trans* 
formation  ensues — the  original  elements  of  the 
structures  concerned  being  consumed  by  the 
destructive  Metamorphosis  which  lakes  place  in 
them,  in  common  with  all  the  tissues  of  the 
2b 


46  TERMINATOR. 

organism.     The  whole  process  may  be  thus  sum- 
med up : 

1.  Inflammatory  action  causing  a  diminution 
of  nervous  influence  in  a  given  tissue,  together 
with  a  loss  of  susceptibility  to  this  influence,  and 
an  abatement  of  its  energy. 

2.  The  constant  destruction  of  the  original 
elements  of  this  tissue,  in  obedience  to  the  general 
law  of  metamorphosis  which  applies  to  the  whole 
organism. 

3.  The  organization  of  Plastic  Lymph,  and  its 
conversion  into  a  tissue  of  inferior  vital  endowment. 

4.  The  entire  substitution  of  this  inferior  tissue 
for  the  original  one,  and  the  consequent  modifi- 
cation of  the  part  both  as  regards  "  structure  and 
function." 

The  most  common  instances  of  this  .degeneration 
or  transformation,  are  the  cellular,  mucous,  cutan- 
eous, fibrous,  calcareous  and  fatty. 

The  Fatty  degeneration  is  the  most  usual  uni- 
versal and  important  of  all,  since  there  is  hardly 
any  organ  or  tissue  of  the  body  in  which  it  may 
not  occur.  It  has  been  observed  in  the  Lungs, 
Placenta,  Cartilages,  Bones,  Cornea,  Lens,  Ar- 
teries, Heart,  Kidneys,  and  Liver — particularly  of 
drunkards — ,  and  constitutes  oae  of  the  most  im- 
portant products  with  which  the  Pathologiest  has 
to  deal. 

It  is  important  to  remember  that  the  various 
tissues  possess  different  degrees  of  vitality,  some 
being  much  more  highly  organized  than  others; 
and,  hence  requiring  dissimalar  conditions  for  the 
full  exercise  of  that  power  by  which  plastic  Lymph 


TERMINATION.-1.  47 

is  converted  or  transformed  into  their  sul 
The  products  now  under  consideration,  differ  from 
the  cacoplastic  deposits,  referred  to  in  another 
connexion,  in  being  more  highly  organized,  and 
in  the  fact  of  their  requiring  the  exercise  of  a 
greater  degree  of  vital  energy  on  the  part  of  the 
affected  tissues  in  order  to  insure  their  develop- 
ment. 

All  the  facts  in  regard  to  the  organization  of  the 
effusion  incident  to  the  Inflammatory  process  may 
be  thus  arranged : 

1.  Inflammation — 

2.  Effusion  of  Plastic  Lymph — 

Organizing  completely,  and  forming  False  Mem- 
branes, or  being  converted  into  the  Elements  ol' 
subjacent  tissue. 

Organizing  incompletely  and  forming  tissues  of 
inferior  vital  endowment  to  those  affected  by 
the  inflammatory  action. 

Organizing  Zc\vy  completely,  and  forming  lle- 
teromorphous  products  generally. 

Not  organizing  at  all,  hut  breaking  down  into 
Pus. 

Death  of  the  Part. — Inflammation  causes  the 
death  of  the  part,  in  which  it  occurs  in  two  ways, 
not  materially  differing  from  each  other  in  their 
essential  nature. 

These  processes,  whith  are  at  once  the  effects  of 
the  Inflammatory  process,  and  the  instrumentali- 
ties by  which  it  accomplishes  its  work  of  destruc- 
tion, are  I'lceration  and  Gangrene. 

Ulceration. — In  atrophy  the  form  and  Btiructure 
of  the  part  remain,  while  the  breaking  down  and 


4S  lERMIEA^OftS. 

absorption  of  its  elements  take  place  with  unusual 
rapidity— more  rapidly,  in  fact,  than  they  can  be 
reproduced.  It  sometimes  occurs  that  this  power 
of  Inflammation  localizes  itself,  and  so  completely 
annihilates  the  equilibrium  between  the  waste  and 
repair— cell-destruction  and  cell-elaboration — of 
a  tissue,  within  certain  prescribed  limits,  as  to  insure 
the  entire  suspension  of  that  Physiological  process 
by  whioh  the  structure  is  built  up,  and  to  stimulate, 
to  an  unusual  degree,  that  destructive  metamor- 
phosis by  which  it  is  broken  down.  There  results? 
consequently,  a  possitive  disorganization  of  the 
part  thus  affected,  with  an  actual  loss  of  its  sub- 
stance— forming  what  is  familiarly  known  as  an 
ulcer. 

It  is  in  this  way,  that  ulcers  are  originally  de- 
veloped, as  the  result  of  Inflammatory  action, 
while  the  particular  features  which  give  them 
character,  are  impressed  upon  them  by  extraneous 
circumstances.  Ulceration  is  therefore  the  local, 
circumscribed  destruction  of  a  tissue, — a  veritable 
dissolution  in  miniature.  The  several  distinct 
pathological  acts  concerned  in  the  development  ot 
an  ulcer  may  be  thus  enumerated: 

1.  An  Inflammation  which  localizes  itself. 

2.  A  suspension  within  circumscribed  boundaries 
of  that  process  by  which  the  tissue  repairs  itself. 

3.  An  unnatural,  morbifl,  excessive  exercise  of 
that  process  by  which  the  waste — cell-distruction- 
of  the  part  is  accomplished. 

4.  A  consequent  solution  of  continuity,  and  the 
pi^esence  as  effete,   extraneous  matter  of  certain 


portions  of  the  tissue  which  have  not  been  so 
readily  or  rapidly  absorbed. 

In  support  of  this  view  of  the  subject  it  is  only 
necessary  to  mention  that  the  debris  of  the  wasted 
tissue  cannot  be  found  either  in  the  Pus  which, 
subsequently  fills  the  ulcer,  or  in  the  Blood  itself — a 
fact  which  demonstrates  that  their  disappearance 
is  due  to  an  exaggeration  of  the  Physiological 
process  by  which  the  destruction  of  tissue  occurs 
throughout  the  whole  organism — or  in  other  words 
that  they  disappear  in  obedience  to  the  ordinary 
law  of  cell-destruction  and  absorption  enforced 
with  extraordinary  energy  and  effect,  through  the 
agency  of  the  Inflammatory  Process. 

For  the  different  varieties  of  ulcers,  with  their 
symptoms,  treatment,  &c,  the  reader  is  referred 
to  the  standard  works  on  Surgery. 

Gangrene. — Gangrene  may  bo  considered  as  a 
partial  death — the  death  of  one  part  of  the  body 
while  the  other  parts  are  alive.  It  may  result  from 
the  violence  of  the  Inflammation  ;  from  an  arrest  of  the 
(  ire illation  ;  and  from  deterioration  of  the  elements 
of  the  Blood. 

The  expression  "violence  "  is  used  relatively  in 
this  connexion — to  convey  the  idea  of  an  Inflam- 
mation not  intrinsically  great,  but  still  too  excessive 
lor  the  part  to  bear  without  serious  detriment. 
The  same  amount  of  vitality  does  not  reside  in  all 
systems,  nor  is  it  distributed  in  equal  proportion  to 
the  tissues  and  members  of  a  particular  organism. 
When  Inflammation  is  developed  in  a  tissue  or 
member,  the  vital  force  of  which  lias  been  lowered, 
and  whose  " formative-power' '  is  lost,   a  peculiar 


50  TERMINATIONS. 

modification  of  structure  occurs,  to  which  the  term 
mortification  is  applied.  In  a  word,  the  tissues  not 
being  supplied  with  their  normal  amount  of  vitali- 
ty because  of  its  consumption  by  the  Inflammatory 
Process,  and  having,  therefore,  lost  the  power  of 
appropriating  the  pabulum  necessary  for  their 
support,  die,  as  a  matter  of  necessity,  while  the 
other  portions  of  the  body  remain  intact.  Atrophy 
indicates  that  the  "formative-power  "  of  the  tissues 
has  been  diminished,  while  a  sufficiency  of  vitality 
remains  to  preserve  their  external  form  and  in- 
ternal organization  ;  ulceration  shows  that  this 
same  power  has  been  lost  within  circumscribed 
limits,  and  that  molecular  death  has  been  the 
result ;  while  Gangrene  illustrates  the  fact  that  this 
ability  to  "appropriate  and  transform,"  has  been 
entirely  destroyed,  even  to  the  extent  of  entire 
tissues  and  members,  with  such  a  diminution  of 
vitality  as  'precludes  the  preservation  of  their 
organization,  and  permits  the  operation  of  ordinary 
chemical  affinities. 

The  circulation  may  be  arrested  by  the  conges- 
tion of  a  part,  and  by  the  pressure  of  effused 
Lymph,  Serum  or  Pus.  In  this  way  the  tissues 
are  deprived  of  their  proper  food,  and  really  die 
of  starvation. 

The  blood  may  be  so  altered  by  Inflammation, 
particularly  of  a  specific  character,  as  to  afford  no 
pabulum  to  the  tissues,  and  to  prove  the  occasion 
of  their  death.  Thus  the  Inflammatory  action 
associated  with  Small  Pox,  Scarlatina,  Erysipelas, 
Pyaemia,  Hospital-Gangrene,  Glanders,  and  other 
diseases  of  a  specific  nature,  terminates  not  un- 


TERMINATIONS.  51 

frequently  in  the  mortification  of  some  part   or 
member  of  the  human  frame. 

[n  some  instances  the  dead  portion  is  dissolved 
away  at  its  circumference  by  an  exudation  from 
the  Jiving  parts,  and  is  thus  separated  or  sloughed 
from  them ;  while,  if  the  dead  portion  be  extensive, 
separation  will  not  be  effected  before  decomposi- 
tion takes  place,  and,  hence,  we  have  what  are 
known  .as  Gangrene  and  Sphacelus. 

Gangrene  may  be  regarded  as  the  state  which 
precedes  and  terminates  in  Sphacelus, — a  condition 
in  which  there  is  great  diminution,  but  not  a  total 
dost  ruction  of  the  powers  of  life, — the  blood  still  cir- 
culating through  the  larger  vessels, — the  nerves 
retaining  some  portion  of  their  sensibility,  and 
the  part  being  not  yet  beyond  the  recuperative 
point. 

By  Sphacelus  is  meant  the  positive  and  irrevoc- 
able death  of  the  part, — the  loss  of  its  organization, 
the  destruction  of  its  component  elements,  the 
suspension  of  its  vital  laws,  and  its  complete  sur- 
render to  chemical  principles  and  affinities. 

Gangrene  has  also  been  divided  into  the  humid} 
dry,  constitutional  and  local.  But  it  is  not  our 
purpose  to  consider  these  varieties  in  detail, 
in  as  much  as  the  same  principles  are  concerned 
in  their  development,  and  similar  laws  apply  to 
their  treatment.  When  mortification  is  about  to 
manifest  itself  as  :i  result  of  Inflammation,  the 
darker  hue ;  heat  and  pain  abate  ; 
and  there  is  a  general  amelioration  of  all  the 
Bymptoms  save   the   swelling  which  generally  in- 


T>2  TEfcftlNATIO 

creases  in  consequence  of  tbe  effusion  of  Sangui- 
nolent  Serum. 

When  Gangrene  terminates  in  Sphacelus  the 
hue  of  part  becomes  dark  and  dirty — the  tissues 
grow  flaccid  and  cold,  while  crepitation  man- 
ifests itself  on  pressure,  and  a  most  offensive  odour 
is  evolved. 

When  the  progress  of  the  Gangrenous  process 
is  arrested,  healthy  circulation  is  developed  up  to 
the  margin  of  the  diseased  portion,  while  a  bright 
red  line — the  line  of  demarcation — indicates  the  es- 
tablishment of  adhesive  Inflammation,  and  shows 
that  the  living  parts  are  to  be  separated  from  the 
dead  by  a  spontaneous  effort  of  nature.  This  line 
of  demarcation  extends  to  the  entire  depth  of  the 
Gangrene,  totally  and  completely  surrounds  it, 
and  by  a  process  of  interstitial  ulceration,  removes 
the  dead  part,  without  hemorrhage  or  other 
serious  inconvenience,  leaving  a  granulating  and 
healthy  surface  behind,  which  undergoes  cicatriza- 
tion without  much  difficulty  or  delay. 

In  some  instances  however,  as  when  Patients 
have  been  subjected  for  a  protracted  period  to  the 
influence  of  debilitating  agencies,  the  blood  does 
not  coagulate  in  the  vessels  and  hemorrhage  of  a 
fatal  character  occurs. 

treatment  or  INFLAMMATION. — As  the  pheno- 
mena of  Inflammation  connect  themselves  both 
with  the  Part  affected  and  with  the  System  at  large\ 
it  is  plain,  that  tbe  remedies  employed  in  its  treat- 
ment ninst.be  of  a  Local  and  a  General  character. 
This  constitutes  the  first  and  most  important  classi- 
fication of  the  remedial  agents  at  the  command  of 


TREATMENT.  53 

the  Surgeon  in  his  contest  with  this  dangerous,  and 
often  defiant  malady,  though  more  minute  sub- 
divisions may  be  necessitated  by  an  accurate  and 
elaborate  investigation  of  the  subject.  From  the 
account  which  has  been  given,  of  the  symptoms, 
products  and  terminations  of  Inflammation,  in  the 
preceding  pages  of  this  work,  it  is  plain,  that  the 
Remedies  employed  in  its  management,  should 
be  used  with  reference  to  the  following  Indica- 
tions : 

1.  To  control  the  response  made  by  the  system 
at  large  to  the  local  disturbance — i.  e.  to  control 
the  adventitious, — non-essential  phenomena  of  In- 
flammation. 

2.  To  control  the  Heat,  Pain,  congestion,  &c. — 
the  essential  phenomena  of  Inflammation. 

3.  To  limit  the  effusions  incident  to  the  Pro- 
cess— i.  e.  to  confine  the  Inflammatory  Action 
within  Physiological  grounds  by  securing  simply 
the  repair  of  tissues. 

4.  To  promote  the  re-absorption  of  the  effusion 
and  to  restore  the  tissues  to  health — i.  e.  to  insure 
Resolution. 

5.  To  prevent  modifications  in  the  structure 
and  functions  of  tissues  and  organs — 

6.  To  prevent  the  death  of  the  part  affected, 
either  molecularly,  by  ulceration,  or  entirely  by 
Gangrene. 

All  General  and  Local  Remedies,  used  in  tin- 
treatment  of  Inflammation,  act  either  by  controlling 
the  phenomena,  limiting  the  effects,  or  modifying 
the  terminations  of  the  Inflammatory  process. 

General  Remedies, — Inflammation  may  be  asso- 


54  TREATMENT. 

ciated  with  a  system  in  a  condition  of  vigor,  or  of 
debility,  and  is  sthenic  or  asthenic  according  to 
the  circumstances  of  the  case.  When  connected 
with  a  healthy  and  vigorous  system,  it  is  usually 
characterized  by  such  symptoms  of  Inflammatory 
Fever, — as  were  referred  to  under  the  head  of 
Sthenic  Fever,  and  when  developed  in  connexion 
with  an  impoverished  and  debilitated  system,  the 
resulting  Febrile  action  is  of  a  Typhoid  character. 
These  facts,  necessitate  a  division  of  the  constitu- 
tional agents  employed  in  the  treatment  of  In- 
flammation into  Depletory  and  Stimulant  Reme- 
dies. 

Depletory  Remedies. — Among  the  most  promin- 
ent agents  which  belong  to  this  class  are  Blood- 
Letting,  Mercury,  Depressants,  Cathartics,  Emet- 
ics, Diuretics,  and  Diaphoretics,  Nervous  Sedatives, 
Agents  which  control  the  Capillary  circulation  and 
the  Anti-philogistic  Regimen. 

Blood-Letting. — Without  entering  into  the 
merits  of  the  great  Blood  Letting  controversy, 
which  has  so  divided  the  Medical  world,  it  will  be 
sufficient  for  present  purposes,  to  mention  the  cir- 
cumstances, &c,  under  which,  according  to  the 
instructions  of  the  ablest  masters,  and  the  teach* 
ings  of  a  sound  therapy,  the  Lancet  may  be  em- 
ployed in  the  treatment  of  Inflammations. 

1.  Blood  Letting  should  never  be  resorted  to 
save  in  Inflammation  which  connects  itself  with  a 
constitution  which  is  strong  and  healthy, — that  for 
instance  of  a  vigorous,  athletic  man. 

2.  When  T    ■      nation,  is  associated  with  Pie- 


TREATMENT.  55 

thora — a  full  habit,  and  an  unusual  supply  of  red 
blood. 

3.  In  Inflammations  which  produce  an  excessive 
disturbance  in  the  system  at  large,  accompanied 
by  a  full  pulse,  hot  skin,  flushed  face,  and  the 
usual  evidences  of  Inflammatory  Fever. 

4.  In  Inflammations  of  some  internal  organ, 
•which  manifests  itself  by  symptoms  of  great  de- 
pression such  as  small  pulse,  cool  skin,  clammy 
perspiration — in  a  constitution  healthy  and  vigor- 
ous up  to  the  moment  of  the  attack. 

5.  In  all  Inflammations  of  a  high  grade,  when  no 
tendency  to  Typhoidism  exists,  and  the  Patient 
can  be  subjected  subsequently  to  proper  treatment 

The  cuds  which  may  be  accomplished  by  Blood- 
letting are: 

1.  To  lessen  the  amount  of  blood  when  it  is  too 
great,  and  to  reduce  its  quality  when  abnormally 
rich  or  stimulant,  and  thus,  to  relieve  Irritation 
ami  Inflammation. 

"2.  To  lessen  the  action,  of  the  Heart  and  Ar- 
teries, to  restrain  the  momentum  of  the  circulat- 
ing fluid,  and  consequently  to  diminish  Heat,  to 
abate  Tain,  to  prevent  effusion,  to  equalize  the 
circulation,  to  obviate  local  determinations,  to 
relieve  spasm  and  nervous  irritation,  and  to  arouse 
usceptibility  of  the  various  organs,  rendered 
insensible  by  the  congestion  of  the  Nervous 
pent 

To  promote  absorption,  and  to  increase  the 
action  of  other  remedies. 

l.  To  arrest  Hemorhage  by  inducing  scyncope, 
and  favoring  the  formation   clots,    by   which   the 


56  TREATMENT. 

Vessels  are  blocked  up,  and  the   escape  of  Blood 
prevented. 

It  cannot  be  denied  however  that  there  are 
multitudes  of  cases,  particularly  in  connexion  with 
the  Surgery  of  Camps,  and  Hospitals,  in  which 
Blood-letting  would  not  be  beneficial,  but  positive- 
ly inj  urious.  But  as  a  pure  anti-phlogistic  when  the 
grade  of  the  Inflammation  is  high  and  the  attend- 
ant conditions  are  such  as  to  admit  of  its  proper 
application,  the  Lancet  has  no  rival,  particularly 
if  employed  before  the  exudation  of  Plastic  Lymph, 
or  the  development  of  those  phenomena  which 
indicate  that  the  acme  of  the  disease  has  been 
passed.  This  can  be  readily  understood,  when  it 
is  remembered,  that  in  Inflammation,  with  each 
pulsation  of  the  Heart  an  unusual  amount  of 
Blood  is  sent  to  the  affected  part,  which  serves  to 
keep  up  and  to  increase  the  already  excited  irrita- 
tion ;  that  the  Blood  itself  is  far  more  stimulant 
than  in  health;  that  the  momentum  of  the  circu- 
lating fluid,  is  greatly  increased ;  and  that  nervous 
irritation  exists  far  beyond  the  natural  limit, — 
morbid  conditions  which  Blood-letting  ameliorates 
and  removes  upon  the  principles  already  enunciat 
ed. 

The  employment  of  the  Lancet  is  based  upon  the 
supposition,  that,  though  the  nervous  centres 
possess  the  inherent  power  of  generating  a  suffi- 
ciency of  vitality  or  nervous  force,  they  are  pre- 
vented from  so  doing  by  the  presence  and  pressure 
of  an  unusual  quantity  of  depraved  Blood,  and 
that  the  proper  performance  of  their  functions  can 
be  facilitated  by  the  removal  of  this  pressure,  and 


TREATMENT.  57 

the  supply  of  a  better  material  for  their  consump- 
tion'. 

Arterial  Sedatives. — Veratrum  Veride,  Digitalis, 
Aconite,  Tartar-Emetic,  &c,  produce  the  same 
effects  as  Blood-letting,  though  in  a  less  marked 
degree,  by  the  impression  which  they  make  upon 
the  circulation.  Under  their  action,  the  skin  re- 
lazes,  the  pulse  softens,  the  tongue  grows  moist, 
Becretions  are  restored,  nervous  irritation  abates, 
and  everything  indicates  the  restoration  of  the 
circulation  to  its  normal  equilibrium,  and  the  abate- 
ment of  the  Inflammatory  symptoms.  Their  em- 
ployment is  particularly  adapted  to  the  cure  of 
Inflammations  of  an  acute  character,  in  young  and 
robust  subjects,  whose  systems  require  to  be  rapid- 
ly impressed  in  order  to  stay  the  march  of  the 
se.  In  Inflammations  of  the  Respiratory 
Organs  their  beneficial  effects  are  so  particularly 
marked  thai  they  have  almost  entirely  supersed- 
ed the  use  of  the  Lancet. 

These  agents  are  not  spolialive.  They  do  not 
deprive  the  system  of  its  blood,  and  thus  rob  the 
[issues  of  their  food.  Their  depressing  effects  are 
feqnsequently  far  more  transient  than  those  pro- 
fituccd  by  tin-  Lancet  :  and,  hence  there  is  not  the 
suiii"  ■  difficulties  to  be  apprehended  in  building  the 
system  up — in  giving  it  tone  and  recuperative 
r  -attendant  upon  their  administration,  as 
upon  the  employment  of  Blood-letting— a  mos( 
important  circumstance  in  these  times  of  Typhoid 
tend  em  ies,  and  low  grades  ol  Fever  generally. 

Mercury. — This     Drug  not     only     controls    the 


58  TREATMENT. 

symptoms  of  Inflammation,  but  limits  its  effects, 
and  modifies  its  terminations. 

It  controls  Inflammation  by  rendering  the  Blood 
less  irritable ;  by  diminishing  the  momentum  of 
the  circulation ;  and  by  promoting  the  secretions, 
and  by  acting  as  a  depletant  and  a  deobstruant. 

It  limits  the  effects  of  Inflammation  by  robbing 
the  Blood  of  its  Plasticity,  and  thus  precludes 
extensive  effusions;  and,  by  releaving  local  con- 
gestion, accomplishes  the  same  end. 

It  modifies  the  terminations  of  Inflammation  by 
liquifying  the  effused  lymph  and   facilitating   its 
absorption— thus  promoting   resolution,  or  "ten 
mination  in   health;"   by   promoting  absorption 
and  obviating  induration;  by  destroying  false  mem 
branes, "— thus   preventing  modifications  in  th 
"structure   and    functions  of  tissues ;  "  and  con-, 
trolling  ulceration  by    altering  the  condition  of 
granulating  surfaces. 
D  Rules  for  the  administration  of  Mercury  : 

1.  Administer  it  in  the  form  of  Calomel,  Blue 
Mass,  or  Mercury  with  Chalk. 

2.  When  from  the  violence  of  the  Inflammation 
a  prompt  and  powerful   impression   is   required 
Calomel  should  be  given  in  large  and  frequently 
repeated  doses. 

S.  When  the  Disease  is  less  violent,  and  the  or-' 
gan  not  important  to  life,  Blue  Mass  or  Mercur| 
with  Chalk  may  be  given  in  smaller  doses. 

4.  To  make  Mercury  more  Purgative  combine 
with  it  finely  powdered  White  Sugar,  and  give 
upon  the  Tongue. 

5.  To  prevent  it  from  running  off  the  Bowel 


TREATMENT.  59 

combine  with  cadi  dose  a  small  quantity  of  Opium. 
<i.  Never  administer  Mercury  without   endeav- 
oring to  ascertain  if  the  Patient  possess  any  Idios- 
yncrasy in  regard  to  it. 

7.  Do  not  administer  Mercury  in  any  form  to 
persons  of  a  strumous  habit,  to  the  very  aged  or  in- 
firm, to  those  whotiave  been  much  enervated  by  the 
depressing  influences  of  bad  clothing,  crowded  and 
ill-ventilated  tents,  and  improper  food,  or  to  the 
consumptive. 

8.  Never  produce  Salivation  designedly,  or  in 
other  words,  suspend  the  medicine  so  soon  as  a 
free  secretion  from  the  Salivan  I  shows  that 
the  system  is  saturated  with  it  e  of  Po- 
tassa,  administered  in  large  an.,  >ii\  Repeat- 
ed doses,  is  the  best  remedy  for  ►Salivation. 

Cathartics,  Diaphoretics  and  Diuretics  are  ad- 
ministered for  their  depleting,  dcrivitive  or  revul- 
sive effects. 

Nervous  Sedatives.  Although  the  part  played 
by  the  Nerves  in  Inflammation  is  not  thoroughly 
understood,  yet  the  following  facts  may  be  re- 
garded as  established  : 

1.  The  primary  morbid  impression  is  made  up- 
on the  nerves,  from  which  it  is  reflected  to  the 
Capillary  Vessels,  and  hence  irritation  and  subse- 
quently congestion  arc  the  primary  phenomena  of 
the  process. 

2.  The  nervous  cenfm,  responding  to  the  per- 
turbation, thus  induced  in  the  economy,  participate 
in  the  irritation,  ami  licnce,  the  circulation  and 
the  secretions,  together  with  the  nutritive  process 
an-  disturbed. 


60  TREATMENT. 

3.  Inflammation  is  as  much  a  product  or  con- 
comitant of  nervous  irritation,  as  of  vascular  dis- 
turbance. 

It  has  been  shown,  that  when  the  Opthalmic 
branch  of  the  fifth  pair  is  divided  in  the  Cranial 
Cavity  of  a  Rabbit  at  the  Varolian  bridge,  Inflam- 
mation is  developed  in  the  surface  of  the  eye,  and 
that,  when  the  nerve  is  cut  in  such  a  way  as  to  di- 
vide the  Ganglion  of  Gasser,  the  Inflammation  is 
more  violent  and  deeply  seated.  It  has  also  been 
demonstrated  that  when  the  Pneumogastic  Nerves 
are  cut  high  up  in  the  neck,  the  Lungs  become 
engorged  with  Blood  and  present  many  of  the 
phenomena  of  Acute  Inflammation,  while  the 
stomach  becomes  also  envolvedto  the  extent  of  an 
arrest  of  its  secretion.  So  likewise  when  the  Bra- 
chial Plexus  is  tied,  the  integuments  and  finally 
the  deep  structures  of  the  Limb  become  inflamed 
in  a  very  high  degree.  These  and  a  multitude 
of  kindred  facts  which  modern  Physiology  has 
established,  demonstrate  that  the  role  performed 
by  the  nerves  in  the  development  and  continuance 
of  the  Inflammatory  Process  is  one  of  the  greatest 
inportance. 

The  Therapeutical  action  of  Sedatives  is  to  di- 
minish the  injection  of  the  nervous  centres,  to 
relieve  the  irritability  of  the  whole  nervous  mass, 
and  thus,  indirectly  to  restrain  the  action  of  the 
Heart,  to  disgorge  the  Capillaries,  and  to  regulate 
the  action  of  the  secreting  organs. 

From  this  plain  statement  in  regard  to  the  con- 
dition of  the  nerves  in  Inflammation,  and  the 
therapeutical   action    of   Sedatives,    it   is    made 


TREATMENT.  61 

apparent  that  this  class  of  remedies  is  peculiarly 
indicated  in  the  treatment  of  that  morbid  process. 
The  agent  which  stands  at  the  head  of  this  list 
is  Opium,  with  its  different  preparations,  as  the 
Salts  of  Morphia,  Laudanum,  and  Dover's  Pow- 
der, though  Stramonium,  Hyosciamus,  Indian 
Hemp,  &c,  may  also  be  employed.  This  remedy  is 
particularly  indicated  when  the  Inflammatory  Pro- 
cess is  accompanied  by  violent  pain,  a  symptom 
which  may  complicate  the  morbid  action  to  a  con- 
siderable degree,  even  to  endangering  the  patient's 
life.     Rules  for  the  administration  of  Opium. 

1.  Precede  the  exhibition  of  the  Opiate,  by 
Bleeding  or  Purgation,  particularly  when  there  is 
Plethora,  Fcecal  distention,  Disorder  of  Secretion, 
&c, 

2.  Administer  it  in  large  doses — say  from  two 
to  four  grains  of  Opium  within  every  twelve  or 
twenty-four  hours. 

3.  Give  the  Opiato  at  night,  so  that  rest  and 
quiet  may  be  secured  to  the  patient. 

4.  Remember,  that  under  the  influence  of  Pain 
the  System  acquires  a  greater  tolerance  for  the 
Opiate. 

5.  If  the  skin  be  dry,  combine  with  the  Drug 
some  Diaphoretic  or  use  Hover's  Powder. 

(>.  When  Inflammation  occurs  in  structures 
which  are  likely  to  be  pu1  in  motion  by  the  nor- 
mal processes  of  the  economy,  as  the  Peritoneum, 
the  Pleura,  the  Alimentary  Canal,  &c,  Opium  may 
be  freely  used,  not  only  for  the  purpose  of  controll- 
ing the  Enflammation  already  existing,  butto  keep 
the  part  at  rest  and  thus  indirectly  to  prevent  the 


62  TREATMENT. 

farther  development  of  it, — by  serving  as  a  verita- 
ble splint  to  the  affected  structure. 

Agents  which  contract  the  Capillaries.  In  those 
cases  where  the  local  disturbance  is  excessive,  ac- 
companied by  great  Heat,  Pain  Congestion,  and 
Swelling,  it  becomes  a  matter  of  importance  to  act 
upon  the  Capillaries  in  such  a  manner  as  to  limit 
the  amount  of  Blood  in  them.  The  remedies  by 
which  this  end  can  be  most  readily  attained  are 
Ergot,  Belladonna,  and  the  Muriated  Tincture  of 
Iron, — agents  which  by  diminishing  the  calibre  of 
the  Vessels,  reduce  the  local  hyperemia,  and  relieve 
the  unfavorable  symptoms  incident  to  it.  Theore- 
ically  these  Remedies,  from  their  known  thera- 
putical  properties,  would  seem  to  be  particularly 
indicated  in  the  treatment  of  that  variety  of  In- 
flammation refered  to  ;  but  as  yet  the  utility  of 
their  administration  has  not  been  subjected  to 
that  practical  test  which  the  Profession  demands 
as  the  essential  condition  of  its  faith  and  confi- 
dence. 

It  must  not  be  supposed  however,  that  these 
agents  act  particularly  upon  the  diseased  part,  for 
it  is  only  by  the  impression  made  upon  the  organ- 
ism in  its  totality  that  the  engorged  Capillaries 
are  incidentally  contracted,  and  the  congestion  re- 
lieved. 

They  are  certainly  worthy  of  a  thorough  and 
impartial  trial,  and  as  such  are  recommended  to 
the  Profession. 

Antiphlogistic  Regimen.  Under  this  head  are 
included  the  diet  of  the  Patient,  and  certain  other 
circumstances  and  conditions  by  which  he  may  be 


TREATMENT.  63 

surrounded.     During  the  height  of  the  Inflamma- 
tion, when  the  functions  arc  interrupted,  the  se- 
cretions deranged,  and  the  Blood  filled   with   sti- 
mulating elements,  great  care  should  be  observed 
in  the  regulation   of  the   diet.     Food  is   usually 
loathed,    under  these   circumstances,   and  when 
injested  in  solid  form,  serves  only  as  an  additional 
source   of  irritation   to   the   system.     When   the 
acme  of  the  affection  has  passed,  mild  and  easily 
digested  food  should  be  administered  in  a  liquid 
form,  beginning  with  gruel,  arrow  root,  &c,  and 
gradually  and  cautiously  advancing  to  other  more 
nutritive   articles.     The   drink  should  be  cooling 
and  demulcent.     The  question  of  diet  in  connexion 
with  the  Inflammatory  Process,  is   an  important 
and  delicate  one.     Care  should  be   taken   to   run 
neither  into  the  extreme  of  over  stimulation  nor  of 
too  great   abstinence ;   but  the    Surgeon    should 
remember  that  there  is  danger  to  be  apprehended 
alike  from  an  excessive  supply  of  pabulum  to  the 
already  infected   Blood,   and   from   the  debility 
which  necessarily  and  in  some  instances,  rapidly 
ensues  from  the   destructive  metamorphosis   inci- 
dent to  Inflammatory  action. 

It  is  also  a  matter  of  the  first  importance  to  se- 
cure perfect  tranquility  of  mind  and  repose  of 
body,  as  well  as  a  proper  amount  of  healthful 
sleep. 

So,  also,  recovery  and  comfort  are  both  promot- 
ed by  a  regular  temperature,  free  ventilation, 
cleanliness  of  body,  words  of  encouragement  'and 
kindness,  clean  and  comfortable  bedding,  the 
presence  of  friends  and  relatives,  the  assurance  of 


64  TREATMENT. 

victory,  confidence  in  the  skill  and  humanity  of  the 
Surgeon,  and  a  multitude  of  similar  circumstances 
which  will  readily  suggest  themselves  to  the 
Physician. 

Stimulants. — This  class  of  remedies  is  indi- 
cated : 

1.  When  the  morbid  action  has  been  originally 
developed  in  connexion  with  a  depraved  and  de- 
bilitated system. 

2.  When  the  strength  of  the  system  has  been 
exhausted  by  the  Inflammation  itself  or  some  of 
its  products,  as  when  Hectic  is  developed  in  con- 
sequence of  the  excessive  discharge  of  Pus,  &c. 

The  principle  upon  which  stimulants  are  exhi- 
bited, in  this  connexion,  may  be  thus  explained. 

The  Nervous  Centres,  which  are  the  great  foun- 
tains of  vitality, — the  sources  from  which  flow  out 
the  influences  which  give  tone  to  the  muscles, 
action  to  the  secerning  organs,  life  and  power  to 
the  whole  organism,  become  debilitated  from  the 
absence  of  those  conditions  which  are  essential  to 
the  health  of  the  system,  such,  for  instance,  as 
pure  and  proper  food,  cleanliness  of  person,  ap- 
propriate clothing,  contentment  of  mind,  and 
other  similar  circumstances.  The  Blood,  at  the 
same  time,  is  impoverished,  losing  its  red  globules, 
augmenting  in  watery  elements,  and  becoming 
more  irritable  and  less  stimulant  to  the  tissues 
through  which  it  circulates.  The  development  of 
Inflammation,  finds  a  system  in  which  these  changes 
have  occurred,  in  but  a  poor  condition  to  resist  its 
invasion,  and  to  prevent  the  induction  of  its  most 


TREATMENT.  65 

unfavorable  consequences.     The    great    centres, 
from  their  preternatural  irritability,  respond  im- 
mediately and  violently  to  the  local  impression,-— 
so  excessively  in  fact,  as  speedily  to  exhaust  them- 
selves, and  to  lose  the  power  of  supplying  that  in- 
fluence upon  which  the  integrity  of  the  Organism 
so  much  depends.  The  tissues  generally  being  thus 
deprived  of  the  stimulus  from  the  Nervous  System, 
are   incapable   of  appropriating   their    necessary 
pabulum.     The    secerning    Organs    having    lost 
their  guiding  and  controlling  principle  fail  in  the 
performance  of  their   legitimate  functions.     The 
chief  motive  power  of  the  circulation  being  weak- 
ened or  destroyed  the  Heart  beats  wildly,  the  ar- 
teries  contract   irregularly,  the     Capillaries    en- 
gorge themselves  with  blood,  and  the  circulating 
fluid  is  vitiated  to  a  still  greater  'degree  under  the 
constantly  increasing  demands  for  its  vitalizing 
principles,  the  retention  of  the  checked  Secretions, 
the    development  of  Inflammatory  products,    the 
waste  of  exhausted  tissue,  and  the  expenditure  of 
its  Carbo-IIygronous  elements  in  the  work  of  Ca- 
lorification.    In  this  emergency,  the  only  means 
of  preventing  speedy   disorganization, — the  com- 
plete overwhelming  of  the  system  by  the  violence 
of  the  disease,  is  to  supply  it  with  strength.     The 
exhausted   fountains   must   be    replenished,    the 
wasted  stream  restored,  the  motive  power  of  the 
paralyzed  machinery  supplied  anew,  or  the  Patient 
surrendered  to  the  embrace  of  death.     Stimulants, 
therefore  become  a  necessity,  so  absolute  and  im- 
perative, that  to   fail  in   their  employment   is   to 
ume  the  responsibility  of  a  fatal  result. 


66  TREATMENT. 

A  simple  illustration  will  elucidate  the  whole 
subject.  The  system  may  be  likened  to  a  Fortress, 
the  Inflammation  to  the  attacking  Party, — the 
first  resisting  the  assault,  the  latter  striving  to  re- 
duce the  Work.  Now,  it  is  plain  that  a  successful 
resistance  can  be  ensured  in  two  ways : — either  by 
weakening  the  attacking  Party,  or  by  strengthen- 
ing the  Fortress.  By  Depletants,  we  diminish  the 
number  and  power  of  the  assailants,  and  thus  en- 
sure the  safety  of  the  Garrison.  By  stimulants, 
we  strengthen  the  weakened  Work,  victual  and 
encourage  its  defenders,  and  secure  the  repulse  of 
the  attacking  Party.  The  one  plan  prevents  fatal 
consequences  by  abating  the  force  and  intensity 
of  the  Inflammation,  while  the  other  accomplishes 
the  same  end  by  strengthening  the  sinking  and 
overpowered  system. 

A  large  majority  of^army  Patients  present 
symptoms  of  debility  in  connexion  with  the  pro- 
gress of  all  Inflammatory  affections,  and  the  ex- 
hibition of  stimulants  and  tonics  is  consequently 
demanded  as  a  general  thing  in  the  treatment  of 
their  diseases.  This  is  the  general  rule,  but  it 
must  be  borne  in  mind  that  it  has  its  exceptions, 
and  is  not  of  universal  application,  as  some  teach 
and  many  believe.  Many  affections  which  assume 
a  Typhoid  type  during  their  progress  and  thus 
necessitate  a  resort  to  sustaining  remedies,  may  bo 
"cut  short"  by  the  timely  employment  of  active 
measures ;  while  it  is  possible  to  stimulate  too  ex- 
cessively even  in  diseases  which  primarily  and 
unequivocally  demand  that  plan  of  treatment.  It 
should  never  be  forgotten  that  debility  is  as  surely 


TREATMENT. 


67 


and  speedily  produced  by  surfeiting  the  Nervous 
Centres  with  too  great  an  abundance  of  the  rich 
food  which  alcoholic  Preparations  supply,  and  by 
over  taxing  their  generating  properties  by  ex- 
cessive aud  protracted  stimulation,  as  by  any 
other  possible  means,  and  that  Carbon  and  Hydro- 
gen, whilst  subserving  valuable  purposes  in  the 
economy,  are  not  the  elements  from  which  the 
most  important  structures  of  the  organism  gather 
their  vitality  or  power. 

In  exemplification  of  the  truth  of  these  observa- 
tions, it  is  only  necessary  to  refer  to  the  recorded 
experience  of  Dr.  Gualla,  Surgeon  in  chief  of  the 
military  Hospitals  at  Brescia,  in  regard  to  the  treat- 
ment of  the  wounded  after  the  battle  of  Solferino. 
He  declares  that  the  Italian  soldiers  who  fought  up- 
on their  own  soil,  in  their  native  climate,  in  their 
full  vigor  and  health,  and  not  exhausted  by  long 
marches,  or  injured  by  unusual  food,  recovered 
rapidly  from  their  wounds,  though  subjected  uni- 
versally to  an  Antiphlogistic  treatment;  wrhile  the 
French  soldiers,  who  were  weakened  by  the  dan- 
gerous and  protracted  march  over  Mount  Cenis, 
Buffered  greatly  and  died  in  large  numbers,  though 
treated  on  opposite  principles.  The  greater  sufrer- 
ing  and  mortality  of  the  latter,  he  ascribes  to  the 
fact  that  they  were  allowed  too  rich  a  diet,  and 
stimulated  to  an  unreasonable  extent,  notwithstand- 
ing their  previous  debility.  It  is  much  to  be  ap- 
prehended, that  under  the  extravagant  teaching* 
oi'Tod.l,  Ben  net,  and  others  of  their  School,  the 
death  blow  of  many  an  unfortunate  victim  has 
been  given  in  the  excessive  potations  administered 


68  TREATMENT. 

for  his  comfort  or  relief.  The  Surgeon  should 
enter  upon  the  discharge  of  his  most  responsible 
task  with  an  honest  determination  to  discard  all 
bias  and  prejudice  in  regard  to  particular 'modes  of 
treatment,  and  with  "in 'medio  tutissimus  ibis"  as  his 
rule,  should  only  depart  from  it  after  a  thorough 
individualization  of  each  particular  case,  and  an 
accurate  knowledge  of  all  the  surrounding  circum- 
stances. 

Stimulants  and  tonics  have  been  spoken  of  in- 
discriminately, for  the  reason  that  the  one  is  so 
administered  as  to  secure  'permanency  of  impression 
and  the  other  employed  in  such  a  manner  as  to 
ensure  rapidity  of  action,  thus  approximating  them 
therapeutically,  and  making  them  subserve  the 
same  ends  in  the  economy.  The  Remedies  of  this 
class  in  general  use,  are  Alcoholic  Liquors  of  all 
kinds,  Wines,  preparations  of  Ammonia,  Sulphate 
of  Quinia,  and  Tinctura  Muriatici  Ferri,  &c. 

The  alcoholic  liquors  stand  at  the  head  of  the 
list,  in  as  much  as  they  can  be  more  conveniently 
obtained  and  administered;  as  their  effects  upon 
the  system  are  prompt  and  decided;  as  they  are 
better  borne  by  the  stomachs  of  most  men;  and  as 
they  are  more  palitable  and  agreeable  to  a  large 
majority  of  Patients. 

Rules  for  the  administration  of  alcoholic  stimulants — 

1.  Examine  well  into  the  present  condition  and 
previous  habits  of  the  Patient  before  administering 
them. 

2.  Commence  with  small  quantities — say  half 
an  ounce,  and  gradually  increase  the  dose  accord- 
ing to  the  necessities  of  the  case. 


TREATMENT.  69 

3.  Administer  at  such  intervals  as  will  ensure 
a  prompt,  continuous  and  equable  impression  up- 
on the  system. 

4.  Watch  the  condition  of  the  stomach,  care- 
fully, lest  an  initiation  of  that  organ  be  develop- 
ed, thereby  interfering  with  the  absorption  of  the 
stimulant  and  adding  to  the  burdens  of  the  labor- 
ing system. 

5.  Examine  the  Pupil  frequently,  noticing 
whether  it  be  contracted  or  dilated  abnormally 
and  discontinuing  the  Remedy  from  the  fear  of 
cerebral  Inflammation  in  the  one  instance  or  a  ex- 
cessive congestion  in  the  other. 

6.  Attend  strictly  to  the  circulation,  continuing 
the  medicine,  if  the  Heart  beats  more  slowly  un- 
der its  influence,  or  continues  at  its  original  rate, 
and  rejecting  the  stimulant  when  its  pulsations 
are  excessively  increased  in  frequency  and  force. 

7.  If  Coma  be  produced,  Delirium  increased,  or 
sleep  prevented,  change  the  treatment. 

8.  If  the  Tongue  grow  red  and  cracked,  the 
month  dry,  deglutition  difficult,  and  the  voice 
husky,  stimulants  are  contra-indicated  and  should 
be  abandoned. 

9.  [f  the  Kidneys  or  Skin — particularly  the  lat- 
ter— be  too  much  acted  on,  thereby  debilitating 
the  Patient,  stimulate  carefully. 

10.  If  the  Heat,  Pain,  and  congestion  of  the 
part  increase,  or  the  wound  looks  redder,  fails  to 
suppurate,  or  discharges  Pus  too  freely,  the  reme- 
dy should  be  discontinued. 

11.  On  the  other  hand,  when   noue  of  the  acci 

3b 


70  TREATMENT. 

dents  just  mentioned  present  themselves,  and  the 
attendant  phenomena  assume  an  opposite  charac- 
ter, the  Surgeon  should  not  be  alarmed  at  the 
quantity  of  the  stimulant  employed,  but  being 
guided  alone  by  its  effects,  and  observing  the  pro- 
gress of  the  case  with  the  most  intelligent  scru- 
tiny, he  should  push  his  advantage  until  the  sys- 
tem has  secured  an  entire  mastery  of  the  Disease. 

In  regard  to  the  particular  preparation  of  Alco- 
hol which  should  be  employed,  the  fancy  of  the 
•Patient,  or  the  convenience  of  the  Surgeon  may 
be  consulted  when  good  Liquors  are  within  reach. 
Whiskey  is  usually  preferred,  because  when  pure  (?) 
it  is  more  acceptable  and  less  irritating  to  the  stom- 
ach ;  while  French  Brandy  also  has  its  champions. 
In  the  present  condition  of  the  Country,  Apple 
Brandy  is  the  purest,  most  palatable,  and  least  dif- 
ficult to  procure,  since  distillation  from  grain  has 
been  prohibited ;  while  experience  has  convinced 
the  Author,  that  as  a  pure  stimulant  it  stands  un- 
equaled. 

The  manner  in  which  the  other  Remedies  refer- 
red to  under  this  head,  are  employed  will  be  more 
fully  considered  in  various  connexions. 

Local  Remedies. — These  are  either  \weiicntwe 
or  curative,  according  to  the  end  for  which  they  are 
employed.  The  most  prominent  and  important 
among  them  are  Rest,  Position,  Local  Depletion, 
Revulsives,  Cold  and  Warm  Applications,  Topi- 
cal Alteratives,  and  Compression. 

Rest. — The  importance  of  steady  and  persis- 
tent rest,  can  readily  be  understood,  when  it  is  re- 
membered that  the  least  exercise  of  the  part  ne-^ 


TREATMENT.  71 

cessitatcs  the  flow  to  it  of  a  large  amount  of  blood 
and  nervous  influence  "VThere  Best  cannot  be 
secured  by  the  Patient's  own  efforts,  Splints  may- 
be employed,  or  Opium  used  for  the  purpose  of 
temporarily  paralyzing  the  muscular  fibres  of  the 
affected  structures.  It  is  well  not  to  continue  this 
treatment  long,  lest  anchylosis,  permanent  immo- 
bility, &c.,  be  the  consequence. 

Position. — In  Inflammation  the  vessels  are  filled 
with  an  unusual  amount  of  Blood,  which  is  still 
controlled  by  the  laws  of  gravity, — accumulating 
in  a  dependent  part,  and  vice  versa.  This  is  true 
for  the  other  fluids  as  Serum,  Lymph  and  Pus 
which  are  developed  in  connexion  with  the  pro- 
cess of  the  morbid  action.  So  likewise  position 
may  increase  the  pain  of  the  affected  part,  by 
causing  muscular  pressure  upon  it.  For  these 
reasons,  the  part  should  bo  kept  in  an  elevated 
position,  and  so  arranged  as  to  relax  its  muscles, 
while  the  comfort  of  the  Patient  should  likewise 
be  consulted  as  far  as  practicable. 

Local  Depletion. —  This  is  accomplished  by 
means  of  Scarifications,  Punctures,  Leeches,  Cups, 
and  Drainage.  The  Blood  may  be  taken  di- 
rectly from  the  part  by  local  bleedings,  or  rob- 
bed of  its  serum  by  Blisters.  These  remedies  al- 
ercise  an  indirect  control  through  the  agency 
of  nervous  reflex  action,  or  by  their  general  se- 
dative e fleets  upon  the  system  at  large.  Blisters 
should  always  be  employed  with  caution  particu- 
larly in  the  earlier  Btages  of  Inflammation,  lest 
they  add  to  the  irritation  of  the  diseased  structure, 
and  thus  prove  an  injury  rather  than  a  benefit  to 


72  TKEATMENT. 

the  Patient.  Punctures  are  employed  for  the  pur- 
pose of  relieving  the  suffering  tissues  of  the  Se- 
rum or  Pus  which  may  have  been  poured  out  in 
them.  The  artificial  evacuation  of  Pus  may  be 
accomplished  either  directly  by  the  Knife,  by 
Caustic — though  the  latter  is  seldom  attempted — or, 
by  what  is  known  as  Drainage. 

Bides  for  opening  Abscesses. — 1.  Take  care  in  in- 
troducing the  Bistoury  not  to  interfere  with  any 
important  nerve,  to  open  a  large  vessel,  or  to  pen- 
etrate one  of  the  large  cavities  of  the  Body. 

2.  Make  the  opening  great  enough  to  ensure  a 
free  vent  of  the  pent  up  fluid.  It  is  far  better  that 
the  opening  should  be  too  large  than  too  small. 

3.  Assist  the  evacuation  if  necessary,  by  the 
hand  or  linger,  used  however,  with  the  greatest 
gentleness. 

4.  Prevent  the  incision  from  healing  by  "  First 
Intention,"  by  inserting  a  small  tent  made  of  old 
linen,  well  oiled,  and  interposed  between  the  edg- 
es of  the  wound. 

5.  Employ  the  "warm  water  dressi-ng"  or  an 
E  moll  ientCataplasm(?)for  the  purpose  of  promoting 
the  discharge  of  the  fluid,  after  the  bleeding  has 
ceased,  but  be  careful  not  to  continue  it  for  too 
long  a  period  lest  too  much  relaxation  ensue. 

6.  Approximate  the  sides  of  large  abscesses  by 
means  of  compresses. 

7.  Make  the  opening,  if  possible,  so  that  gravi- 
tation will  promote  the  escape  of  the  purulent 
matter,  but  if  this  cannot  be  effected,  try  a  counter- 
opening.  A  current  of  water  passed  from  one  open- 
ing to  the  other  is  frequently  of  great  advantage. 


TREATMENT.  73 

8.  If  arteries  be  divided  in  the  operation,  ligate 
them. 

Chaissaignac  has  proposed  to  relieve  abscesses  of 
their  coutents  by  a  system  of  "Drainage,"  which 
is,  in  fact,  but  a  revival  of  the  old  doctrine  of  the 
Seton.  He  plunges  a  Trocar  lined  with  a  Canula 
through  the  abscess  and  out  again  through  the  in- 
tegument ;then  withdrawing  the  Trocar,  he  passes 
through  the  Canula,  which  remains  behind,  a  tube 
of  India  Rubber,  perforated  with  holes  for  the  es- 
cape of  the  matter,  and  ties  the  two  ends  togeth- 
er. In  this  way  the  escape  of  Pus  and  Serum  is 
facilitated,  and  a  collapse  of  the  parts  secured, 
while  the  introduction  of  atmosphenc  air — an 
agent  which  promotes  suppuration  while  it  de- 
composes Pus — is  entirely  prevented. 

Cold  and  "Warm  Applications. — This  class  em- 
braces everything  from  the  "Cold  water  dre*  sin-"  to 
the  "Medicated  Poultice."  Though  Cold  "Water  has 
been  used  in  the  treatment  of  Inflammation  from 
the  earliest  times,  the  experience  of  Ambrose  Pare 
has  mainly  contributed  to  the  elevation  of  the 
remedy  to  its  proper  position  in  the  estimation  of 
Military  Surgeons.  It  has  perhaps  boon  more 
universally  employed,  in  the  War  which  is  now 
being  waged  by  the  Confederacy  than  in  any  oth- 
er previous  struggle,  and  with  results,  which  when 
properly  tabulated,  will  astonish  the  world.  To  Sur- 
geon J.  J.  Chisolm,  Professor  of  Surgery  in  the 
Medical  College  ot  South-Carolina,  and  Author 
of  the  best  "Manual  of  Military  Surgery"  that 
has  been  published  in  any  language,  we  are  in- 
debted for  the  just  appreciation  in  which  this  in- 


74  TREATMENT. 

valuable  mode  of  treatment  is  held,  at  the  present 
time.  If-  he  had  done  nothing  more  than  incul- 
cate, in  that  able  work,  his  most  scientific  and  ra- 
tional views  in  regard  to  the  Cold  Water  treat- 
ment of  wounds,  he  would  deserve  the  lasting 
gratitude  of  the  Profession  and  of  the  Public. 

Truly  it  may  be  said,  the  days  of  Cerates,  Oint- 
ments, and  Cataplasm  has  passed, — having  been 
swept  to  oblivion  by  the  copious  streams  of  Cold 
Water,  with  which  an  enlightened  Surgery  has 
comforted  and  relieved  the  mutilated  victims  of 
a  thousand  Battle  Fields. 

The  advantages  of  "  Cold  Water  Dressings" 
in  all  stages  of  Inflammation,  as  local  applications, 
may  be  thus  summed  up  : 

1.  Cold  Water  is  clean,  cheap,  simple  and  gen- 
erally agreeable  to  the  feelings  of  the  Patient. 

2.  It  enables  the  Patient  himself,  or  the  most 
ignorant  assistant,  to  dress  the  wound. 

3.  It  keeps  down  the  temperature  of  the  parts, 
constrains  the  Capillaries,  and  relieves  Hyperse- 
mia. 

4.  By  forcing  the  Blood  out  of  the  Capillaries 
and  preventing  its  passage  into  them,  the  source 
from  which  Pus  is  developed,  is  thus  cut  oft,  and  the 
suppurative  process  arrested.  It  has  been  conclu- 
sively demonstrated  that  the  process  of  suppura- 
tion, so  far  from  being  necessary  to  the  healing  of 
wounds,  or  the  arrest  of  Inflammation,  retards  the 
one  and  seriously  complicates  the  other.  The  im- 
portance, therefore,  of  Cold  Water  Dressings, 
even  in  the  most  advanced  stages  of  Inflammation 
is  thus  made  apparent. 


TREATMENT.  t5 

6.  It  relieves  nervous  irritation,  and  thus,  both 
directly  and  indirectly  controls  the  Inflammatory 
process. 

Cold  Water  may  be  applied  in  various  ways,  as 
by  saturating  Linen,  Cotton  Cloths,  Sponge,  &c, 
and  frequently  squeezing  them  over  or  constantly 
applying  them  to  the  part ;  by  suspending  a  Buck- 
et and  then  by  means  of  a  narrow  strip  of  Cloth, 
on  a  lamp  wick,  conducting  a  stream  of  Cold  Wa- 
ter to  it;  by  elevating  a  funnel  above  the  part  af- 
fected, filling  its  nozzle  with  lint  and  permitting 
the  Water  to  percolate  through  it  from  above;  by 
means  ot  Bladders  tilled  with  pounded  Ice;  and  by 
many  other  contrivances  which  the  circumstances 
of  the  case  will  suggest  to  the  Surgeon.  Care 
should  always  be  taken  to  prevent  the  bed  cloth- 
ing, and  the  clothes  of  the  Patient  from  becoming 
saturated,  lest  he  be  chilled  or  inconvenienced 
thereby.  In  some  instauces,  though  they  are  rare, 
Cold  Water  cannot  be  borne  at  first,  when  Tepid 
Water  should  be  substituted  for  it  temporarily, 
taking  pains,  however,  to  lower  the  temperature 
of  the  application,  gradually  but  decidedly,  until 
that  degree  has  been  reached  at  which  "'  sedation 
and  astringency"  manifest  themselves. 

Warm  Applications. — The  circumstances  under 
which  Warm  applications  are  demanded,  may  be 
thus  stated  : 

1.  When  the  Blond  lias  .-<>  completely  stagnated 
at  certain  points,  as  i"  become  insensible  to  the 
visatergo  warm  applications  may  l>c  sometimes 
employed,  lor  the  purpose  of  adding  to  the  volume 
and  force  of  the  Blood  current  flowing  towards 


76  TREATMENT. 

the  part,  and  of  thus  indirectly  relieving  the  Ca- 
pillary congestion. 

2.  When  an  unusual  amount  of  irritability  ex- 
ists in  the  nerves  of  the  affected  tissues,  manifest- 
ing itself  in  great  pain,  tenderness,  sensations  of 
cold,  spasm,  &c,  warm  applications  are  indica. 
ted,  in  as  much  as  the  resulting  Hypersemia  though 
inevitable  is  the  lesser  of  the  two  evils. 

3.  When,  from  the  extreme  delicacy  of  the  Pa- 
tient's organization,  his  tendency  to  pulmonary 
irritation,  the  existence  of .  bronchial  affections,  or 
the  impossibility  of  making  cold  applications  with 
that  regularity  and  system  requisite  for  the  preser- 
vation at  an  equable  temperature,  the  "  Cold  Wa- 
ter" treatment  is  countra-indicated. 

4.  When  the  part  affected  assumes  a  glazed? 
red,  dry  and  angry  appearance,  manifesting  no 
disposition  to  heal  by  the  "First  Intention,"  re- 
sisting the  application  of  Cold  Water,  and  pro- 
gressing but  slowly  towards  any  termination, 
warm  applications  may  be  employed  with  advan- 
tage. 

5.  When  a  wound  which  has  suppurated  freely 
suddenly  ceases  to  do  so,  without  indicating  a  ten- 
dency to  heal,  either  with  a  total  abolition  of  the 
sensibility  of  the  part,  or  an  extraordinary  aug- 
mentation of  it,  Warm  Water  may  take  the  place 
of  Cold. 

The  instances,  however,  in  which  Warm  water 
is  required  to  the  entire  exclusion  of  Cold  appli- 
cation, are  of  comparatively  rare  occurrence  ;  and 
the  Surgeon  should  hesitate  and  most  carefully 
consider  the  indications  before  concluding  to  make 


Treatment.  77 

tlie  substitution.  If  there  Jbe  any  doubt  in  regard 
to  the  matter,  give  the  Patient  the  benefit  of  it, 
and  continue  the  Gold  Watei* 

It  should  not  bo  forgotten,  that  the  exposure  of 
wounds  in  which  Inflammatory  action  has  been 
developed,  to  vicissitudes  of  temperature  is  the 
prolific  source  of  Tetanus;  and  hence,  whether 
Cold  or  Warm  AVater  be  selected,  use  it  freely 
and  persistently — in  such  a  manner  as  will  main- 
tain an  equable  temperature  in  the  part. 

Should  it  become  necessary  to  employ  a  poultice, 
a  soft  wet  Compress,  covered  with  oil  silk,  and 
Secured  by  a  flannel  roller  or  outer  Compress,  will 
fulfill  any  possible  indication.  The  proper  thermal 
status  is  preserved  by  the  absorption  of  animal 
heat,  the  application  is  light  and  comfortable, 
medication  can  be  readily  effected,  the  materials 
are  always  attainable,  cleanliness  can  be  invariably 
insured,  and,  in  fact,  so  many  advantages  present 
themselves  in  connexion  with  it  as  to  "preclude 
all  substitutes." 

Either  cold  or  warm  water  can  be  medicated, 
with  Sugar  of  Lead,  Sulphate  of  Zinc,  Tannin, 
Spirits  of  Camphor,  Preparations  of  Opium,  Tinc- 
ture of  Arnica,  and  according  to  the  presenting 
indications.  The  temperature  of  the  Water  can 
be  lowered  by  the  addition  of  Alcohol,  common 
Salt,  or  a  strong  solution  of  Nypcrchlorate  ot 
Ammonia  and  Nitrate  of  Potassa. 

Revulsives. —  U(ri  irritatio  ibi  affluxus  est  is  a 
pathological  axiom,  and  upon  it  the  whole  problem 
of  (he  revellent  action  of  Medicines  is  based.  The 
system  possesses  but  a  definite  amount  of  Blood  and 


78  TREATMENT.  " 

Nervous  force,  and  by  securing  their  accumulation 
at  one  point,  all  other  parts  are  relieved  of  them 
to  a  certain  extent.  *Counter  irritants  are  employ- 
ed in  the  treatment  of  Inflammation  for  the  pur- 
pose of  creating  a  new  disease,  which,  by  attracting 
the  Blood,  &c,  to  itself  may  serve  as  a  diverticulum 
for  the  part  originally  affected.  Great  judgment 
is  required  in  determining  ivhere  and  ivhcn  to  apply 
them,  since  if  not  wisely  employed  they  increase 
rather  than  abate  the  morbid  action.  As  a  general 
rule  they  should  not  be  used  until  after  some  pre- 
liminary depletion  has  been  practised,  while  care 
should  be  taken  not  to  apply  them  too  near  a*" 
delicately  organized  structure,  or  too  far  from  one 
of  a  different  character.  To  this  class  belong 
Rubefaciants,  Blisters,  and  Suppurants. 

Local  Alteratives. — The  most  prominent  of 
these  are  Nitrate  of  Silver,  and  Iodine.  The  first 
named  is  used  extensively  in  acute  Inflammations 
as  a  topical  antiphlogistic  agent,  while  the  other  is 
more  particularly  employed  to  promote  the  re- 
absorption  of  Lymph,  as  in  dissipating  a  gathering 
abcess,  andsoftening  an  indurated  tissue. 

Nitrate  of  Silver  is  not  only  a  powerful  vesi- 
cant or  destructive,  but  by  substituting  a  new  and 
more  controllable  action  of  its  own  for  the  one 
existing  in  the  part,  it  serves  as  a  valuable  auxiliary 
in  the  treatment  of  Inflammation.  Its  action  may 
be  thus  stated — 

1.  As  a  vesicant,  producing  counter  irritation, 
and  controlling  Inflammatory  action,  as  explained  . 
above. 


TREATMENT.  79 

2.  Destroying  tissue  and  thus  assisting  nature 
in  her  work  of  elimination,  as  in  Gangrene. 

3.  Neutralizing  certain  causes  of  Inflammation, 
as  virus  of  the  serpent,  the  poison  of  the  cadaver, 
and  thus  indirectly  restraining  that  morbid  pro- 
cess. 

4.  Producing  certain  changes  in  animal  struc- 
tures, such  as  prevent  the  progress  of  Inflamma- 
tion ;  and  hence  used  in  Erysipelas  and  Hospital 
Gangrene. 

5.  Substituting  a  new  and  more  manageable 
action  of  its  own  for  the  existing  Inflammation, — 
as  in  Gonorrhoea,  &c. 

Iodine  acts  upon  the  absorbent  vessels,  and  sti- 
mulates them  to  a  more  vigorous  discharge  of  their 
duties;  and  like  all  other  alteratives,  controls  the 
great  work  of  cell-development,  and  cell-destruc- 
tive,— the  metamorphosis^  and  nutrition  of  the 
tissues. 

^Compression.— The  afllux  of  Blood  to  an  in- 
flamed part  may  be  prevented  by  mechanical 
means,  and  that  local  congestion  prevented  from 
which  effusion  ensues  with  its  attendant  conse- 
quences. Nor  is  this  all,  spasm  may  be  controlled 
in  this  way,  the  absorbent  vessels  stimulated,  the 
affected  structures  supported,  and  effusions  pre- 
vented,— results  of  the  most  vital  importance  to 
the  individual  parts  and  to  the  whole  organism. 
The  means  of  Compression  are  the  common  band- 
age and  adhesive  plaster,  so  applied  as  to  make 
:  le  and  agreeable  pressure  over  the  whole  of  the 
affected  struetui 


80  TREATMENT. 

In  all  that  has  heen  said  as  regards  the  pheno- 
mena, pathology  and  treatment  of  Inflammation, 
a  direct  reference  has  heen  had  to  the  acute  form 
"of  that  affection,  as  it  is  with  that  variety  particu- 
larly that  the  military  Surgeon  has  to  contend 
alike  in  Camp,  Field  and  Hospital. 


CHAPTER   II. 


AMPUTATIONS  IN  GENERAL. 

Varieties  op  Amputation. — Amputations  arc 
Primary  or  Secondary,  according  to  the  period  at 
which  they  are  performed. 

Primary  Amputations  are  those  undertaken  for 
direct  injury,  and  are  performed  either  immediate- 
ly after  the  wound  has  been  received,  or  after  re- 
covery from  the  Shock  and  before  the  develop- 
ment of  Inflammation. 

By  the  term  Shock  is  meant  that  condition  of 
the  nervous  system  which  sooner  or  later  en- 
sues upon  particular  injuries  in  certain  persons. 
It  is  characterized  by  coldness  of  the  surface,  pal- 
lor, tremors,  an  anxious  expression  of  the  coun- 
tenance, small,  irregular  and  feeble  pulse,  sighing 
respiration,  partial  or  complete  paralysis  of  the 
bladder,  mental  disturbance  and  Incoherence  of 
speech.  This  condition  may  continue  for  a  long- 
er or  shorter  period,  but  usually  disappears  in  a  few 
hours  ;  while  the  intensity  of  the  shock  is  not  al- 
ia direct  proportion  to  the  extent  or  severity 
of  the  wound,  as  it  is  sometimes  very  greal  even 
where  the  injury  is  trivial.  It  it  persist  however, 
whether  the  injury  be  seemingly  great  or  small, 


82  PRIMARY  AMPUTATIONS. 

there  is  always  danger  to  be  apprehended,  and  the 
Surgeon  should  prepare  himself  to  meet  it. 

The  evidence  of  the  English  Naval  Surgeons,  as 
summed  up  by  Hutchison,  when  taken  in  connex- 
ion with  that  supplied  by  Macleod  from  his  Cri- 
mean experience,  clearly  establishes  the  fact  that 
the  condition  which  is  known  as  Shock  is  not  ne- 
cessarily established  immediately  upon  the  re- 
ceipt of  the  injury,  but  that  an  interval  ensues 
which  differs  in  duration  according  to  the  severity 
of  the  wound,  the  agency  producing  the  injury, 
or  the  constitutional  status  of  the  sufferer. 

The  Circumstances  under  which  immediate  Ampu- 
tations are  demanded  are  : 

1.  "When  the  Shock  is  delayed.  The  importance 
of  seizing  upon  the  moments  of  comparative  tran- 
quility which  frequently  elapse  between  the  re- 
ceipt of  the  injury  and  the  development  of  Shock, 
was  first  recognized  by  Ambrose  Pare  and  Rich- 
ard Wiseman,  and  is  now  growing  into  favor  with 
the  Profession. 

2.  "When  the  Nervous  Depression  is  slight,  or 
is  not  developed  at  all,  as  sometimes  occurs. — 
Larrey  declared  that  he  had  lost  a  great  number  of 
Soldiers  by  delaying  the  operation  too  long,  with- 
in the  first  twenty-four  hours,  and  recommended 
Amputation  as  one  of  the  surest  means  of  reliev- 
ing the  "commotion,"  and  of  diminishing  its  dan- 
gers. When  the  Shock  is  slight  it  certainly 
should  constitute  no  centra-indication  to  the  use 
of  the  knife. 

3.  When  a  limb  is  either  nearly  or  completely 


PRIMARY  AMPUTATIONS.  83 

torn   off,  and  a  dangerous  hemorrhage  is  occurr- 
ing which  cannot  be  arrested. 

4.  When  the  smaller  members,  as  the  fingers 
or  toes  are  seriously  injured. 

5.  When  Broken  Bones,  Fragments  of  Shell, 
splinters,  clothing,  or  other  foreign  substances 
are  lying  in  the  track  of  the  wound  in  such  a  man- 
ner as  to  preclude  their  extraction,  and  to  induce 
such  anjamountof  pain  and  nervous  commotion  gen- 
erally as  threatens  the  immediate  destruction  of 
life.  In  eases  like  these,  even  the  teachings  of 
Larrey  may  be  followed  and  the  operation  perform- 
ed whether  the  shock  exist  or  not. 

In  deciding  upon  the  practicability  of  this  oper- 
ation, it  is  important  to  take  into  consideration 
the  moral  condition  of  the  Patient.  All  Army 
Surgeons  know  that  men  are  brought  from  the 
field  of  battle,  either  enthused  by  the  combat,  in- 
different "to  all  save  the  "  fate  of  the  day,'.'  and 
willing  to  submit  to  any  thing  which  gives  a  pro- 
mise of  future  revenge,  and  the  prospect  of  a  parti- 
cipation in  the  triumph  of  their  comrades,  or  dis- 
pirited, disheartened,  and  depressed, both  physically 
and  mentally  by  the  appearance  or  the  pains  of 
their  wounds  and  the  idea  of  permanent  mutila- 
tion. The  meanest  coward,  under  the  strange  in- 
fatuation of  the  Battle  Field, — the  roar  of  Cannon, 
the  flashing  of  the  deadly  Bayonet,  the  deeds  of 
daring  done  round  him,  the  stirring  notes  of  com- 
mand, the  presence  of  his  comrades  and  all  the 
wild  excitement  of  the  stirring  scene  may  forget 
his  own  mortality  and  be  transformed  into  a  hero, 
who,  while  the  fit  is  on  him,  will  despise  the  steel 


84  PRIMARY  AMPUTATIONS. 

of  the  Surgeon  as  thoroughly  as  the  Bullets  of  the 
foe.  On  the  other  hand,  the  Soldier  who  has 
marched  to  the  cannon's  mouth,  insensible  to  fear, 
and  dreaming  only  of  revenge  or  triumph,  is  par- 
alyzed by  the  flowing  of  his  own  blood,  and  is 
borne  to  the  rear  in  mortal  terror  of  an  operation 
by  which  additional  pain  is  to  be  inflicted  or  de- 
formity entailed  upon  him.  In  the  one  case,  the 
Surgeon  could  perform  the  operation  with  impu- 
nity, while  in  the  other  still  greater  depression 
would  follow  each  stroke  of  the  knife,  and  per- 
haps speedily  terminate  his  existence. 

Upon  general  principles,  it  might  be  supposed 
that  the  soldier  would  bear  an  amputation  better 
when  "heated  and  in  mettle" — when  excited  by 
the  combat  and  within  sound  of  the  cannon,  pro- 
vided he  be  not  completely  prostrated  by  the 
shock — than  when  opportunity  had  been  offered 
for  tne  abatement  of  his  excitement,  and  calm  re- 
flection upon  the  dangers  and  inconvenience  of 
the  loss  he  is  to  sustain  ;  and  hence,  if  it  be  not 
contra-indicated  by  other  circumstances,  an  imme- 
diate operation  may  be  resorted  to. 

The  circumstances  which  demand  the  performance 
of  amputations — subsequent  to  the  abatement  of  the 
shock  and  prior  to  the  development  of  Inflamma- 
tion, are  : 

1.  The  tearing  off  or  crushing  of  an  entire  limb, 
without  the  accompaniment  of  an  uncontrollable 
Hemorrhage,  and  with  the  complication  of  nervous 
shock. 

2.  Compound  or  multiple  fractures,  especially 
of  the  lower  extremities,  accompanied  by   great 


PRIMARY    AMPUTATIONS.  5 

laceration  of  the  soft  parts,  such   as   amounts   to 
their  purification. 

5.  Complicated  Fractures,  involving  the  section 
both  of  the  chief  Vessel  and  Nerve  of  the  member. 

6.  Simple  Fracture  complicated  by  the  opening 
of  one  of  the  large  articulations,  and  the  tearing 
of  its  ligaments. 

7.  Great  injury  of  soft  parts  unaccompanied  by 
fracture,  with  the  division  of  their  main  arterial 
trunks  or  nervous  filaments. 

8.  Extcusive  destruction  of  the  integuments, 
such  as  precludes  the  possibility  of  cicatrization 
within  a  reasonable  time. 

9.  Fractures  accompanied  with  extensive  con- 
tusion, generally  demand  Amputation.  Exten- 
sive contusion  necessitates  amputation  more  than 
open  laceration,  even  of  great  extent. 

A  complete  revolution  has  taken  place  within 
the  present  century,  in  regard  to  the  advanti 
of  Primary  when  compared  with  Secondary  oper- 
ations.    The  opinions   of  Faure   have  been  en- 
tirely overturned  by  the  more  philosophical  v 
of  Boucher,   dispite  the  decisi* 
Academy:  and   the   mostcnligji! 
has  indicated  the  wisdom  and  humanity 
ing  to  early  Amputations,  especially  in  mili 
surgery. 

When  the  circumstances  of  the  case  do  not 
lily  an  immediate  operation,  tin  hould 

administer  a  cup  of  cool  yater,  (hen  vine,  bran- 
dy or  food  if  possible,  ancrdrcss  the  wounds  tem- 
porarily, wailing  for  the  establishment  of  reac- 
tion  before  proceeding  to  take  tho  proper  steps 


86  PRIMARY   AMPUTATIONS. 

for  the  performance  of  the  later  Amputation. — 
Words  of  encouragement  and  kindness,  whether 
the  sufferer  be  friend  or  foe,  should  never  be  neg- 
lected by  the  medical  officer,  as  the  moral  condi- 
tion of  the  patient  plays  a  most  important  part 
in  relieving  the  nervous  depression  incident  to 
his  physical  mutilation. 

Reaction  should  occur  within  48  hours  after  the 
receipt  of  the  injury,  even  in  the  worst  cases,  and 
Primary  Amputations  are  supposed  to  be  perform- 
ed within  that  time. 

JRulcs  for  performing  Primary  Amjmtaiions. — 
1.  Operate  within  forty-eight  hours  after  the  re- 
ceipt of  the  injury. 

2.  Operate  as  far  from  the  trunk  as  possible,  as 
every  inch  saved  diminishes  the  risk  of  the  patient's 
life. 

3.  Operate  as  soon  after  recovery  from  Nervous 
Shock,  and  as  much  before  the  development  of  In- 
ftamatpry  reaction  as  possible. 

4.  Operate  at  a  joint  rather  than  go  beyond   it. 

5.  Keep  the  patient  underthc  influence  of  Chlo- 
roform no  longer  than  is  absolutely  necessary. 

0.  Cut  rapidly,  tie  qnickly,  dress  slowly,  and 
bandage  lightly. 

7.  Guard  against  the  development  of  nervous 
depression,  or  of  excessive  vascular  reaction,  and 
stimulate  or  deplete  according  to  the  necessities  of 
the  case. 

8.  Let  the  knife  JoMow  the  condemnation  of  the 
limb  as  speedily  as  practicable. 

9.- Operate   upon  the  lower  limbs  for  injuries 


ONDARY   AMPUTATIONS. 

which  would  nol  demand  the  condemnation  of  the 
superior  extremities. 

There  are  various  oilier  principles  which  should 
guide  the  Surgeon  in  the  performance  of  these 
operations,  but  as  they  apply  with  equal  force  to 
all  Amputations,  they  will  he  considered  under  a 
different  head. 

Second  ub  i  A.mputations. — Secondary  Amputa- 
tions as  distinguished  from.  Primary,  are  those 
performed  after  the  Inflammation  which  super- 
venes upon  the  injury,  has  been  developed. 

There  arc  two  varieties  of  Secondary  Amputa^ 
tion,  viz  : — those  which  are  performed  be/on  the 
Inflammatory  action  has  abated — during  the  In- 
flammatory Fever:  and  those  which  are  perform- 
ed after  the  subsidence,  partial  or  complete,  oi 
the  Inflammatory  action,  and  in  connexion  with 
some   of  its  products,  particularly  Pus. 

The  Circumstances  which  justify  Amputations  du- 
ring the  existence  of  Inflammatory  F<  ver,  are  : 

I.    Excessive    and    uncontrollable    lieinorrl. 
occurring  al  that  period. 

•J.  Tetanic  symptoms  manifesting  themselves 
in  connexion  with  the  wound,  and  resisting  all 
remedii 

:!.  Indications  ofa  tendency  to  debility  rapidh 
and  unexpectedly  showing  themselvi 

4.   A   sudden  necessity  demanding  the  immedi- 
ate  removal   of  the  patient,  when    it  is  manifest 
Unit  th«-  dangers   incident    to   transportation  are 
iter  than  those  of  the  operation. 


88  SECONDARY    AMPUTATIONS. 

The  Impropriety  of  operating  as  a  general  rule, 
before  the  subsidence  of  the  Inflammatory  pro- 
cess— when  a  great  amount  of  perturbation  exists 
both  in  the  Nervous  and  Vascular  systems — is  too 
plain  to  require  demonstration.  Cases,  however, 
do  present  themselves  when  the  risk  must  be  ta- 
ken, and  the  Amputation  perfoimed  without  re- 
gard to  the  principles  which  ordinarily  control 
tbe  Surgeon  in  this  connexion. 

It  is  impossible  to  establish  any  definite  and 
universal  law  in  this  regard;  and  the  Surgeon 
can  only  be  enjoined  to  individualize  each  parti- 
cular case,  weighing  the  danger  of  delay,  thor- 
oughly comprehending  the  risk  of  the  operation, 
and  duly  estimating  the  nature,  extent  and  poten- 
cy of  the  emegrency  before  him. 

These  operations  sometimes  do  astonishingly 
well,  surprising  both  operator  and  patient  by  pro- 
gressing speedily  and  surely  to  a  favorable  termi- 
nation. 

The  Circumstances  which  necessitate  Secondary  op- 
erations proper,  or  those  undertaken  after  the  abater 
ment  of  the  Inflammatory  process,  and  tin:  forma- 
tion of  its  products,  are  : 

1.  Secondary  Hemorrhage,  occurring  at  a  late 
period  in  the  history  of  the  case. 

2.  Rapid  and  excessive  formation  of  Pus,  jeop- 
ardizing the  life  of  the  patient. 

3.  Mortification  rapidly  developing  itself. 

4.  Rapidly   decreasing  strength  of  the  patient. 

5.  Necrosis  and  malignant  diseases  of  bone,  or 
extensive  and  exhausting  ulceration  of  the  Soft 
Parts,  defying  other  remedies. 


><i>  \'.;\    \miti  vno-NS. 


89 


6*  Diseases  oi  the  Joints,  especially  those  oJ    o 
malignant  character. 

7.  The  appearance  of  Tetanic  symptoms. 

These  contingencies   and   various  others   of  a 
similar  character,  which  will  readily  suggest  them 
selves  to  the  mind  of  the  Surgeon,  will  justify  him 
in  resorting  to  Secondary  operations. 

Rules  for  th    performarii  condary  Amputa- 

tions.— 1.  Operate   as  far  from  (ahove)  the  seal  of 
injury  as  practicable. 

2.   ( Operate  above  a  joint  rather  than  at  it. 

:'>.  Operate  before  the  strength  ot  the  patient  i 
too  much  exhausted,  and  before  Pus  has  been  ab 
sorbed,  if  practicable. 

4.  Operate,    as   a  general   rule,  after  the  su 
dence  of  Inflammatory  Fever,  the  developmenl  oi 
a   free    and   healthy  suppuration,  and  the  restora- 
tion of  the  skin  to  its  normal  functions,  particular- 
ly in  the  affected  limb. 

5.  Operate  in  rases  of  traumatic  gangrene — 
save  in  frost-bites  and  burns — just  SO  soon  as  the 
first  symptoms  show  themselves  :  but  in  constitu- 
tional oridiopathic  gangrene,  wait  lor  the  line  of 
demarcation. 

<i.  Avoid   hemorrhage,   during  the  amputation? 
ar  as  possible,  support  the  strength  of  the  pa- 
tient and  watch  carefully  for  symptoms  of   puru- 
lent absorption. 

1     heral  Observations.— The  great  question  of 
the  comparative  value  of  Primary  and  Secondary 
Amputations  in  Military  Siirgery,may  be  regard- 
ed  as  definitely  settled.     The  experience' of  the 


90  OBSERVATIONS.. 

English,  French,  and  Kussian  Surgeons  in  the 
Crimean  war,  establishes  beyond  the  possibility  of 
refutation  that  the  results  of  Primary  are  far  more 
favorable  than  those  of  Secondary  .Amputations. 
Thus  Macleod  declares,  "the  experience  of  the 
Crimea  in  favor  of  early  operation  was  unequivo- 
cal in  both  armies."  M.  Salleron,  who  was  in 
charge  of  the  Dolma  Bagtchc  Hospital  at  Constan- 
tinople, asserts  that  from  the  1st  of  May  to  the  1st 
of  November,  1855,  "the  total  number  of  Ampu- 
tations was  G39,  ie.  490  Amputations  in  continui- 
ty and  149  disarticulations.  Of  the  639,  419  were 
Primary  operations,  furnishing  221  recoveries  and 
198  deaths ;  220  were  .Secondary,  furnishing  73  re- 
coveries and  147  deaths.  Thus  among  the  639 
cases  there  were  294  recoveries  and  345  deaths, 
the  Primary  operations  yeilding  more  than  half of 
the  cures,  and  the  Secondary  operations  yielding 
not  a  third."  The  Kussian  Surgeons  report  that 
"they  lost  two-thirds  of  all  their  Secondary  opera- 
tions, but  saved  a  fair  number  of  their  Primary." 
So  likewise  after  the  battle  of  Solferino,  according 
to  Dr.  Gualla,  Surgeon  in  chief  of  the  Austrian 
Military  Hospitals  in  Brescia,  Amputations  per- 
formed shortly  after  the  injury  was  done,  showed 
a  much  more  favorable  issue  than  those  underta- 
ken later  in  the  stage  of  advanced  suppuration,  the 
proportional  result  in  favor  of  life  was. nearly  two 
to  one."  Chisolm  asserts  that  the  experience  of 
every  battle  field  shows  that  the  mortality  follow- 
ing the  Amputation  of  limbs,  which  require  im- 
mediate  operation  is   ahvays  less  than  those  per- 


OBSERVATIONS. 

formed    sonic    days  after  the   infliction   oi    the 

wound. 

From  the  statistics  on  file  in  the  Surgeon  Gen- 
eral's Office,  it  appears  that  there  were  performed 
in  and  around  Jiichmond,  from  June  1st,  1862,  to 
August  1st,  1S<>;_\  272  Primary  Amputations — fur- 
nishing 190  recoveries  and  82  deaths,  and  308 
Secondary  amputations, giving  145  recoveries  and 
163  deaths.  For  fuller  information  in  regard  to 
this  subject  the  reader  is  referred  to  the  tallies 
which  constitute  the  Appendix  to  this  work. — 
These  tables  were  prepared  with  great  care  by 
Surgeon  F.  Sorrell,  Inspector  of  Hospitals  for  the 
City  of  Richmond,  Ya.,  under  the  immediate  su- 
pervision of  Surgeon  General  S.  P.  Moore,  ('.  8. 
A.,  and  constitute  an  invaluable  contribution  to 
Surgical  science.  In  thus  collecting  and  perpetu- 
ating these  important  facts,  they  have  stamped 
their  names  in  indelible  characters  upon  the  pro- 
fessional history  of  the  times. 

The  term  "  Intermediate  "  is  employed  in  these 
tables  evidently  to  designate  operations  which 
were  performed  neither  immediatel}-  subsequent 
to  the  shook,  nor  after  the  development  of  suppura- 
tion ;  and.it  consequently  corresponds  with  what  has 
been  treated  of  in  these  pages  as  a  Secondary  Am- 
putation made  in  the  first  period — during  the  exis- 
tence of  [nflamramatory  reaction. 

It  is  true  that  these  views  in  regard  to  Primary 
Amputations,  are  opposed  by  many  Surgeons  of 
great  ability,  such  as  Faure,  Hunter,  Percy,  Blan- 
din  and  Mause,  but  they  are  mainly  of  the  last 
century,  and  the  weight    of  authority  preponder- 


02  OBSERVATIONS. 

'  ates  greatly  upon  the  side  of  Primary  Amputations 
in  military  surgery. 

Dr.  John  Stone,  after  a  most  careful  and  elabo- 
rate investigation  of  this  subject,  both  in  its  mili- 
tary and  civil  practice,  thus  sums  up  his  conclu- 
sions: 

1.  Primary  Amputations  of  the  upper  extremi- 
ties are  more  successful!,  and  to  be  preferred  both 
in  military  and  civil  surgery. 

2.  That  in  military  surgery,  Primary  Amputa- 
tions of  the  lower  extremeties  arc  twice  as  success- 
ful as  Secondary. 

8.  That  in  civil  Surgery  it  is  immaterial  wheth- 
er Primary  or  Secondary  Amputations  of  the  low- 
er extremeties  arc  resorted  to. 

4.  That  Secondary  Amputations  of  the  upper 
extremities  in  civil  surgery  are  8  per  cent,  less  fa- 
tal than  in  military  surgery. 

o.  That  Secondary7  Amputation  in  civil  surgery 
are  12  per  cent,  less  fatal  than  in  military  sur- 
gery. 

There  is  another  view  of  this  subject  which 
should  not  be  overlooked.  The  number  who  sur- 
vive after  a  given  number  of  Primary  and  Secon- 
dary Amputations  does  not  afford  a  proper  index 
of  the  relative  value  of  the  two  operations.  The 
most  severely  injured  have  their  limbs  removed 
early  ;  while  the  milder  cases  are  reserved  for  Se- 
.  condary  Amputation.  In  estimating,  therefore, 
the  value  of  the  two  operations,  an  account  must 
be  taken  of  the  more  unfavorable  circumstances 
which   practically   surround  early  operations,  ren- 


98 

tiering    death  inevitable  in  many  cases,  or  materi 
ally  retarding  recovery  in  others. 

So  likewise  thequestion  is  not  whether  a  hun 
dred  men  freshly  wounded  and  requiring  Amputa 
lion  are  more  likely  to  survive  than  ahuudredwho 
bave  gone  through  the  dangerous  ordeal  of  a  llos 
pital;  but  whether  the  first  hundred  would  live 
to  thai  period — the  probability  being  that  they 
would  not. 

In  view  of  all  the  tacts  of  the  case,  the  conclu- 
sion   is  inevitable,  that  Primary  A.ruputations  tire 
tar  more  successful  than    Secondary,  and  that  hu- 
manity and  science  unite  in  demanding  their  per 
forniance  whenever  practicable. 

Instruments. — If  possible  the  Surgeon  should 
have  always  on  baud  and  ready  {'or  use,  Knives, 
Saws,  Forceps,  Tenaculre,  Bone  Nippers,  Sponges, 
a  lietraetor,  Threaded  Needles,  Adhesive  or  [sin- 
glass,  Plaster,  a  Tourniquet,  Cold  Water,  Brandy, 
and  Chloroform.  Amputations,  however,  have  been 
performed  with  no  other  instruments  than  a  well- 
sharpend  Carving  or  Bowie  Knife,  a  common  Saw, 
and  a  Fork  bent  in  such  a  manner  as  to  serve  as  a 
Tenaculum;  and  no  Surgeon  will  ever  permit  his 
patient  to  die  from  an  exhausting  and  uncontroll- 
able Hemorrhage  or  any  sirumilar  accident,  for 
the  want  of  an  operation,  when  these  implements 
can  be  procured. 

It  has  become  fashion able  to  decry  the  Tourni- 
quet, and  many  repudiate  it  altogether.  The 
abuse  of  a  thing  is  no  argument  against  it  when 
properly    used;  am!,  though  there  arc, many  and 

serious  objections  t<»  this  Enstrumenl  asordiuarily 

li.  ' 


04  TOURNIQUET. 

employed  it .may  be  made  to  subserve  moat  important 
purposes  in  the  hands  of  a  judicious  operator.  It  is 
true  that  it  only  controls  the  bleeding  when  tight" 
ly  applied,  and  that  when  so  applied  it  acts  as  a  gen- 
eral ligature  around  the  member,  and  can  be  used 
but  for  a  short  time  without  injury  to  the  limb, 
and,  yet,  within  the  brief  period  in  which  it  can 
be  used,  the  fate  of  the  patient  may  be  decided. 
The  experience  of  every  practical  Surgeon  will 
confirm  the  assertion,  that,  in  multitudes  of  in- 
stances, either  from  the  ignorance,  fright  or  fa- 
tigue of  the  assistant  engaged  in  controlling  the 
Artery,  or  from  some  sudden  spasmodic  motion  of 
the  patient  himself,  the  Vessel  slips  from  beneath 
the  compr&ssing  finger  and  permits  the  escape  of 
that  precious  "fluid,  whose  every  drop  is  required 
by  the  necessities  of  the  weakened  system.  To 
find  a  new  assistant  may  be  difficult,  to  search 
again  for  the  Artery  in  the  midst  of  the  patient's 
struggles  requires  time,  while  but  a  few  turns  of 
the  Screw,  if  the  Tourniquet  has  been  previously 
adjusted,  will  obviate  all  occasion  for  delay,  and 
by  arresting  the  flow,  snatch  the  patient  from  the 
hands  of  death.  Again,  it  frequently  happens, 
that  in  consequence  of  some  abnormal  develop- 
ment of  the  Vascular  System  either  congenital  or 
the  product  of  morbid  action,  sufficient  digital 
compression  cannot  be  made  to  prevent  the  flow 
of  Blood,  and  the  Tourniquet  comes  in  as  a  most 
valuable  auxiliary  in  the  arrest  of  the  inevitable 
and  most  destructive  Hemorrhage  which  follows 
the  Knife. 
It  is  therefore  best  not  to  discard  the  Tourniquet 


TOURNIQUET.  95 

entirely  but  to  adjust  it  upon  the  Limb  loosely  and 
yet  in  such  a  manner  as  to  enable  the  Operator  to 
command  the  artery  in  an  emergency,  so  that  in 
the  event  of  the  accident  referred  to,  the  screw 
may  be  turned  and  the  Hemorrhage  arrested. — 
This  plan  is  entirely  practicable,  and,  while  it  ob- 
viates the  objection  to  the  instrument,  fulfills  a 
most  important  and  preponderating  indication. 

( Horofprm. — The  discovery  of  the  anaesthetic  ef- 
fects of  Chloroform  is  the  great  surgical  achieve- 
ment   of  the    age.     Under  its  soothing  influence 
operations  have  been   performed  -which  otherwise 
would  have  been  impossible,  while  the  amount  of 
suffering  obviated  cannot  be  estimated  in  words. 
It   has    thus    extended   the    domain   of  Surgery, 
crowned  the  noble  science  with  fresher  and  proud- 
er laurels,  and  proved  a  source  of  incalculable'com. 
fort  and   security  to  the  human  race.     That  acci- 
dents of  a  serious  character  have  attended  its  ad- 
ministration, and  that  it  docs  occasionally  produce 
fatal  consequences  cannot  be  doubted.  •  And  vet, 
when    the    immense    advantages  which  it  secures, 
both    to    the   operator  and   the   patient,  togeth- 
er with  the  comparative  in-fi'equency  of  these  unfor- 
tunate results,  arc  taken  into  the  account,  theargu- 
nients  so  speciously  urged  against  its  employment; 
are  rendered  utterly  nugatory  and  abortive. 

Thus  Velpeau  declares  that  he  has  emplovcd 
Chloroform  more  than  five  thousand  times  with- 
out a  single  accident.  Baudens  affirms  that  the 
French  Surgeons  in  the  Liussian  war,  '-had  no  fa- 
tal accident  to  deplore  from  its. use,  although  it 
was   employed  thirty  thousand  times  or  more." 


OG  CHLOROFORM. 

Macleod  states  that  though  almost  universally 
employed  by  the  English  Surgeons  in  the  Crimean 
Campaign,  but  one  fatal  result  could,  with  any 
show  of  fairness  be  attributed  to  it.  At. Guy's 
Hospital,  Chloroform  was  used  12,000  times  before 
there  was  any'  serious  accident.  Dr.  Gross  says 
that  he  has  given  Chloroform  for  more  than  ten 
years  without  an  unfavorable  result  in  any  case. 

In  a  word,  it  has  been  demonstrated  by  the  stern 
logic  of  facts  that  this  invaluable  agent  is  far  less 
dangerous  than  was  supposed  in  the  earlier  days  of 
its  history — less  dangerous  than  many  other  reme- 
dies which  are  daily  used  without  stint  or  lim- 
itation by  those  who  most  bitterly  and  pertinaci- 
ously oppose  the  administration  of  Chloroform. 

The  advantages  which  attend  its  administration 
are : 

1.  The  abolition  of  all  pain — a  fact  which  im- 
proves the  moral  condition  both  of  Operator  and  Pa- 
tient, with  reference  to  the  operation. 

2.  The  induction  of  a  condition  of  tranquility, 
in  which  the  muscles  are  passive,  all  motion  sus- 
pended, and  the  patient  is  entirely  under  the  con- 
trol of  the  Surgeon,  so  that  more  difficult,  pro- 
tracted, and  nicer  operations  can  be  performed. 

3.  The  suspension  of  sensibility  permitting  the 
more  thorough  examination  of  wounds. 

4.  The  arrest  of  Hemorrhage,  during  the  oper- 
ation. M.  Chassaignac  has  particularly  called  the 
attention  of  Surgeons  to  this  important  fact.  Ac- 
cording to  the  observations  of  this  distinguished 
operator,  both  the  Arterial  and  Venous  circula- 
tions  are   materially   controlled  by  this  agent — a 


CHLOROFOJRM.  97 

conclusion  which  must  be  sustained  by  the  expe- 
rience oT  medical  men  generally  whose  opportuni- 
for  an  investigation  of  this  subject  have  been 
sufficiently  extensive.  In  order  to  give  a  rational 
account  of  the  forces,  in  virtue  of  which  these  phe- 
nomena take  place,  it  is  only  sufficient  to  compare 
the  condition  of  a  patient  operated  on  in  the  ordi- 
nary state,  with  that  of  one  under  the  anesthetic 
influence  of  Chloroform.  In  the  one  the  appre- 
hension of  the  operation  about  to  take  place  in- 
creases the  number  of  pulsations,  and  augments 
the  cardiac  impulse;  while  the  disturbance  Oi 
the  respiration,  and  the  efforts  made  by  the  pa- 
tient, when  restrained  by  the  Assistants,  retards 
the  free  return  of  Venous  Blood.  An  increase  in 
the  force  and  frequency  of  the  pulsations  of  tho 
Heart,  and  a  retardation  of  the  Venous  flow  are 
the  circulatory  conditions  of  those  who  are  submit- 
ted to  operations  without  the  employment  of  ai 
thetics.  When  Chloroform  is  administered  there 
ensues  a  diminution  in  the  frequency  and  force  of 
the  pulse,  together  with  an  establishment  of  the 
normal  condition  of  the  respiration,  and  the  in- 
duction.of  a  state  of  perfect  tranquility  and  quie- 
tude. 

This  fact  should  be  remembered  by  the  Surgeon 
in  connexion  with  the  application  of  dressings,  as 
the  chances  of  ulterior  hemorrhage  art."  greater  in 
proportion  as  less  Blood  has  been  lost  during  the 
operation. 

RuUs  i       th    Administration   of   CJrforoform. — 
1.   Place  the  Patienl  in  a  recumbent  position, 
to  maintain  a  proper  circulation  in  the  Brain,  and 


98  CHLOROFORM. 

as  a  means  of  avoiding *tlie  disadvantages  of  great 
muscular  relaxation. 

2.  Remove  all  causes  which  arc  likely  to  inter- 
fere with  the  Respiratory  Function  by  controlling 
the  Diaphragm — such  as  tight  clothing,  heavy  cov- 
ering, sword,  belts,  &c.  Upon  the  same  principle, 
avoid  the  administration  of  Chloroform  on  a  full 
stomach. 

3.  See  to  the  introduction  of  an  abundant  sup- 
ply of  Atmospheric  Air  with  the  vapor  of  the  an- 
esthetic. This  is  absolutely^ dispensable  to  the 
safety  of  the  Patient,  both  as  a  means  of  prevent- 
ing too  great  an  accumulation  of  Carbonic  Acid 
in  the  Blood,  and  the  possible  development  of  Car- 
bonic Oxide.  All  the  Inhalers  which  have  been 
invented  are  objectionable  on  account  of  their  in- 
convenience and  the  difficulty  of  obtaining  a  prop- 
er supply  of  Atmospheric  Air.  The  best  mode  of 
administering  Chloroform  is  by  means  of  a  cloth, 
folded  in  the  form  of  a  cone,  in  the  apex  of  which 
a  small  piece  of  sponge  is  placed.  This,  im- 
pregnated with  a  drachm  of  Chloroform,  should 
be  held  over  the  mouth  and  nose,  at  a  distance  of 
about  two  inches,  being  gradually  approximated 
until  within  one  inch  of  the  face,  beyond  which  it 
should  not  be  carried.  Great  care  should  be  taken 
not  to  force  the  cloth  down  upon  the  face  of  the 
patient,  lest  respiration  be  interfered  with  and  suf- 
focation ensue. 

-1.  In  Primary  Amputations  particularly,  and 
in  those  undertaken  after  the  development  of  Pus, 
precede  the  anaesthetic  by  an  ounce  of  brandy  or 


CHLOROFORM  99 

'whiskey,  and  repeat,  thedoso  if  the  pulse  becomes 
very  weak. 

5.  See  thai  complete  anajsthesia  be  induced  and 
kept  up  until  the  operation  is  completed,  but 
watch  the  pulse  and  breathing  carefully  lest 
it  be  carried  too  far.  This  should  be  made  the 
special  business  of  the  assistant  to  whom  the  In- 
halation is  confided,  taking  care  to  select  an  expe- 
rienced man  for  this  purpose. 

6.  Discontinue  the  remedy  temporarily  when  the 
breathing  becomes  toisy,  when  the  insensibility  of 
the  skin  is  lost,  and  when  muscular  power  is  abol- 
ished- -as  is  shown  by  the  falling  ofthe  arm  or  leg 
when  raised  from  the  bed,  the  dropping  oftheeyelid 
when  opened,  &c.  If,  in  connexion  with  these  phe- 
nomena, the  pulse  does  not  become  too  feeble, 
anaesthesia  is  perfect  and  the  operation  may  be 
performed  without  the  fear  of  fatal  consequences. 

Much  discussion  lias  taken  place  in  regard  to 
the  quantity  o\'  Chloroform  which  should  be  ad- 
ministered; but,  as  the  strength  of  the  article  ma- 
terially varies,  and  as  the  susceptibilities  of  pa- 
tients differ  widely,  it  is  plain  that  nospecific  quan- 
tity can  be  fixed  upon  in  this  connexion.  Let  it 
be  freely  but  cautiously  administered  without  re- 
gard to  the  quantity  consumed,  and  with  an  eye 
single  to  i  he  effects  produced.  When  much  blood 
has  been  lost,  absorption  is  more  rapid,  and  a 
smaller  quantity  is  required. 

A   consideration  oi  the  modus  operandi  of  Chlo- 
roform  doe- not  legitimately  pertain  to  a  work  of 
this  description  ;  and  it  is  therefore  only  nec< 
ry  to  remark  thai  its  ultimate  effects  are  those  of  a 


100  CHLOROFORM. 

powerful  sedative  to  the  ETervous  System — a  fact 
which   should   never  be  forgotten  or  disregarded. 

Notwithstanding  that  sedation  is  induced  by  it  in 
the  system  and  the  dangers  which  attend  its  ad- 
ministration on  that  account,  its  usefulness  is  par- 
ticularly apparent  in  connexion  with  operations 
performed  immediately  aiipon  the  receipt  of  inju- 
ries. Under  these  circumstances,  it  seems  to  ward 
off  that  commotion  of  the  nervous  system  which 
we  denominate  Shock,  and  to  prevent  the  fatal  con- 
sequences incident  to  that  condition,  by  taking 
possession  of  the  great  centres  and  appropriating 
them  exclusively  to  its  own  purposes. 

Disastrous  Effects. — Though  (Jkloroform  has 
proved  an  inestimable  boon  to  the  human  race,  it 
is  potent  for  evil  also.  Effects  sometimes  follow 
its  administration  which  all  the  skill  of  the  Sur- 
geon cannot  restrain,  and  which  necessitate  the 
speedy  sacrifice  of  the  patient's  life.  The  modes 
in  which  these  unfortunate  results  are  produced 
are : 

1.  By  an  interference  with  the  functions  of  the 
brain — either  from  the  congestion  of  that  organ 
or  the  presence  in  it  of  too  much  impure  blood. 

2.  By  an  interference  with  the  respiratory  func- 
tion. This  results  from  the  sedative  impression 
made  upon  the  nervous  centres  which  preside  over 
that  important  function,  and  the  interruption  of 
the  process  of  pulmonary  osmosis  upon  which  its 
integrity  depends. 

3.  By  inducing  certain  alterations  in  the  blood. 
The  changes  in  the  blood  which  attend  the  inha- 
lation of  Chloroform  are  the  accumulation  in  it  of 


CHLOROFORM.  101 

an  unusual  amount  of  Carbonic  Acid,  the  absence 
ol  a  proper  amount  of  Oxygen,  and  the  develop- 
ment   of  Carbonic  Oxide.     The  accumulation  ol 
Carbonic  Acid,  and  tha  absenceof  Oxygen,  which 
is  the  vitalizing  element  of  the  tissues,  can  be  read- 
ily understood  when  it  is  remembered  to  what  an 
extent  (lie  respiratory  function  is  interfered  with  ; 
while  the  development  of  Carbonic  Oxide,  can  like- 
wise be  readily  explained.      The  tissues,  through 
which  this  altered  blood  circulates,  have  a  natural 
affinity  for  Oxygen — an  affinity  which  increases  in 
intensity  just  in  proportion  as  there  is  a  deficiency 
of  it.        So  imperative^  does   their    demand   be- 
come, that   the  Carbonic  Acid  gas  parts  with  one 
of  its  elements  of  Oxygen,  and  is  thus  converted 
into    Carbonic   Oxide — a   most   deleterious  com- 
pound according  to  universal  experience.     I  Bernard 
has  shown  that  Carbonic  Oxide  has  a  greater  affin- 
ity for  the  blood  corpuscles  than  Oxygen  itself,  and 
that  it  forces  them  to  surrender  all  of  this  vitaliz- 
ing principle,  only  to  become  inert  and  effete  mat- 
ter themselves,  incapable  alike  of  stimulating  the 
centres,    of  supplying  the  tissues,  and  ofperform- 
ing  their  appropriate  part  in  the  economy. 

I.  By  interfering  with  the  action  of  the  heart, 
Dalton  has  shown  by  a  scries  of  interesting  arid 
conclusive  experiments-thai  Chloroform  kills  in  a 
majority  of  instances  by  an  instantaneous  and  di- 
rect paralysis  of  the  heart — a  conclusion  which  has 
been  verified  by  other  able  Physiologists.  This 
demonstrates  the  Importance  of  watching  the 
pulse  as  well  as  the  respiration,- and  of  carefully 
noting    all    the    change.-    which    take    place  in  its 


102  CI1LOK0FO11M. 

rhythm,  rate  and  volume,  during  the  performance 
of  an  operation. 

From  the  foregoing  facts  it  becomes  plain  that 
Chloroform  is  contra-indicated  when  organic  dis- 
ease of  the  heart  or  lungs,  and  a  tendency  to  apo- 
plexy exist  in  a  marked  degree. 

Means  for  resuscitating  a  Patient  ivhen  over  dosed 
by  Chloroform. — 1.  Desist  from  farther  administra- 
tion of  the  drug. 

2.  Give  the  patient  an  abundance  of  pure  air,  by 
throwing  open  the  Avindows,  using  the  fan,  and 
sending  off  as  many  assistants  as  can  be  spared. 

3.  Dash  cold  water  with  some  violence  upon  the 
body,   or   pour   it  from  a  heigth  of  several  feet. 

4.  Stimulate  the  surface,  especially  over  the 
spine  and  heart,  with  hot  mustard  water,  dilute 
Spirits  of  Ammonia,  mustard  plaster  saturated  with 
Chloroform. 

5.  Institute  artificial  respiration  by  the  Marshall 
Hall  method. 

6.  Administer  injections  of  turpentine,  or  pour 
Chlorofo.im  over  the  scrotum. 

7.  Apply  galvanism  in  such  a  way  as  to  stimulate 
the  heart  and  diaphragm. 

8.  As  soon  as  the  patient  can  swallow,  adminis- 
ter stimulants,  commencing  with  a  small  quantity 
and  increasing  it. 

9.  Should  the  patient  vomit  turn  him  upon  his 
side  and  not  upon  his  abdomen — so  as  not  to  inter- 
fere with  the  diaphragm — with  the  head  inclining 
downwards. 

Assistants.—  When  'practicable   there  should  be 


1    I  \NTS.  L03 

four  assistants}  viz:  One  to  administer  Chloroform 
andwatch  thepulse;'a  second  to  compress  the  artery 
and  apply  the  Tourniquet  it'  necessary  ;  a  third  to 
hold  the  Limb,  and  retract  the  muscles;  and  a  fourth 
to  lieate  the  arteries.  If  it  be  difficult  to  obtain 
this  number,  the  third  assistant  can  be  made  to  re- 
t  ract  and  ligate  also.  It  is  better  to  have  too  many 
assistants  than  too  lew.  and  the  Surgeon  should 
always  bear  this  in  mind  when  making  his  detail. 
In  field  infirmaries,  Surgeons  will  find  their  duties 
much  lightened  by  a  division  ol  labor,  each  Jop- 
erating  and  assisting  in  turn  —  the  ono  us-' 
ing  the  knife  having  nothing  to  do  with  the  dress- 
ing of  the  stumps,  save  to  exercise  a  general  super- 
vision over  it.  These  directions  are,  of  course,  to 
apply  only  when  there  is  a  lull  complement  of  med- 
ical officers  present — a  rare  circumstance  in  the 
Confederate  service,  and  a  most  unfortunate  one, 
as  the  history  of  every  camp  and  field  attests. — 
When  will  wisdom  be  learned  or  justice  doue  in 
connexion  with  the  medical  department  ol  the 
army? 

Modes  of. Operating.  -The*methods  of  Ampu- 
tating are  known  as  the  Circular,  the  Dovble  Flap, 
the  Single  Flap,  the  Ovaly  and  the  Diaclastic.  Of 
these  various  methods,  tin'  ( Hrcular  and  Double  Flap 

are  most  in  vogue  at  the  present  day. 

The  special  ends  sought  to  he  attained  areto  re- 
tain enough  of  the  Bofl  parts  t<>  cover  the  hone  and 
\o  prevent  its  projecting;  t<>  eftect  as  speedy  and 
firm 'a  cicatrization  as  possible;  and  to  so  cover  the 
stump  that  it  may  not  be  liable  to  excoriate  on  the 


104  CIRCULAR     METHOD. 

least  friction*  The  consecutive  treatment  has  as 
much  to  do  with,  the  fulfillment  of  these  indications 
as  the  choice  of  methods,  and  should;  consequently, 
receive  the  earnest  and  continued  attention  of  the 
Surgeon. 

Circular  Method. — This  dates  its  origin  from  the 
times  of  Celsus,  but  has  been  much  modified  and 
improved  upon  by  Cheselden,  Tetit,  Bell  and  De- 
sault.  It  is  performed  in  two  different  ways. 
The  method  of  Desault.  Directions:  The  first  incis- 
ion is  carried  through  the  skin  and  cellular  tissue 
alone,  being  made  by  one  sweep  of  the  knife,  and 
encircles  the  limb  ;  then  dissect  back  the  skin  with 
a  Bistoury  for  three  inches  ;  and  turn  it  over  in  the 
form  of  a  cuff  (first  recommended  by  Alanson  ;) 
then,  placing  the  knife  upon  the  muscles  near  the 
fold  of  the  skin,  cut  through  them,  by  a  circular 
incision,  to  the  bone — taking  care  to  have  the  edge 
of  the  knife  slightly  turned  towards  the  patient's 
body.  Finally,  retract,  saw  through  the  bone,  li- 
gate  the  arteries,  and  bring  the  wound  in  apposi- 
tion. 

The  Method  of  Petit.— Directions  :  The  skin  be- 
ing firmly  retracted,  make  the  first  incision  through 
it  and  the  cellular  tissue,  by  one  sweep  of  the  knife, 
encircling  the  limb ;  retract  the  skin  still  more 
and  pass  the  point  of  the  knife  under  it  along  the 
whole  extent  of  its  divided  surface;  cut  through 
the  superficial  layer  of  muscles  by  another  circular 
incision';  then  retract  still  more,  and  divide  the 
deep  muscles  to  the  bone.  Use  the  retractor,  denude 
the  bone,  saw  through  it,  and  take  up  the  arteries. 
The  edges  of  the  wound  should  then  be  approxima- 


DOUfiLE    FLAP    METIIOD.  105 

te»I,   and    the  stump   treated   on   general   princi- 
ples. 

Double  Jilcj>  Method. — This  was  devised  by  Ver- 
malc,  and  has  since  been  repeated  with  great  suc- 
cess by  other  Surgeons.  The  Haps  are  formed  in 
two  ways,  either  from  without  inwards,  by  the  meth- 
od of  Langenheck,  by  drawing  the  sort  parts  off 
from  the  bone,  and  then  carrying  the  knife  oblique- 
ly from  the  surface  and  towards  the  bone;  or 
from  within  outwards,  by  transfixing  tbe  limb  with 
a  Jong,  narrow,  and  sharp  pointed  knife,  at  tbe 
point  of  amputation,  and  then  bringing  the  edge 
uely  outwards  to  form  a  flap.  The  same 
process  is  repealed  for  the  opposite  side,  and  in  Ibis 
manner  double  flaps  are  formed. 

The  flaps  having  been  thus  formed,  are  held 
hack  by  the  assistants,  and  all  intervening  tissues 
divided  to  the  bone,  which  is  then  sawed  through. 
Then  take  up  the  arteries,  bring  tbe  flaps  together, 
apply  sutures,  and  dress  tbe  wound. 

Single  Flap  Method. — The  origin  of  this  method 
may  properly  be  referred  to  Loudham,  an  English 
Surgeon,  who  introduced  it  in  1679.  One  flap  is 
made  in  -the  manner  described  under  the  last  head 
and  then,  the  parts  on  the  opposite  side  of  the 
limb  are  divided  down  to  the  bone,  by  a  semi-cii- 
cular  incision.  The  flap  should  be  long  enough  to 
cover  the  stump  ;  and,  alter  the  arteries  have  been 
ligated,  should  be  turned  over  and  secured  to  tbe 
divided  surface  above,  by  means  of  sutures  and 
straps. 

This  operation  is  frequent!)  resorted  to  as  a  mat 
ter  of  uecee  ity,    when    the     ofi    parts  have  been 


106  •      OVAL  METHOD.  ' 

lacerated  higher  up  on  one  side  of  the  limb  than 
the  '  other,  as  frequently  occurs  from  gunshot 
wounds. 

The  Oblique  or  Oval  method. — This  v,  as  first  em- 
ployed by  Langenbeck,  aud  subsequently  by  Guth- 
rie for  the  shoulder  joint.  The  incision,  by  this 
method,  is  carried  around  the  Limb  in  a  sloping 
direction,  which  is  oblique  with  reference  both  to 
the  longitudinal  axis  and  the  perpendicular  diam- 
ter  of  part.  The  remainder  of  the  operation  is 
performed  as  in  the  circular  method. 

Diaclastic  Method  of  Maisonneuve. — M.  Maison- 
neuve  of  Paris  has  proposed  a  new  operation  to 
which  he  has  given  the  name  of  Diaclastic,  or  that 
by  Rupture!  According  this  Surgeon  phlebitis  or 
purulent  absorption  is  the  accident  which  most 
frequently  follows  amputations,  and  decides  the 
case  unfavorably.  It  is  a  matter,  therefore,  of  the 
greatest  possible  moment,  to  resort  to  someSur  gi- 
cal  procedure  by  which  the  part  can  be  readily 
removed,  and  this  fatal  symptom  avoided.  As 
the  surface  of  a  wound  after  amputation  by  the 
knife  presents  a  space  open  to  the  action  and  pene- 
tration of  the  subsequently  formed  purulent  mat- 
ter, he  proposed  to  divide  the  tissues  by  ligatures, 
or  by  "  instruments,  which  like  scissors  bruise  the 
parts  during  division." 

By  means  of  a  peculiar  contrivance,  which  it  is 
unnecessary  to  describe  here  he  fractures  the  bone 
and  then  divides  the  tissues  with'an   instrument 


DTACLAST1C  METHOD.     '  107 

similar  to  the  Ecrasure.J  M.  Maisonneuvo,  after 
many  trials  on  the  dead  subject,  lias  at  length  at- 
tempted the  operation  on  the  living;  but  it  can  only 
be  regarded  as  due  of  ihe  curiosities  of  Surgical 
experience. 

The  more  minute  manipulations  in  these  differ- 
ent methods  will  be  particularly  considered  when 
■  individual  operations  are  discussed. 

General  Remarks. — Much  diversity  of  opinion 
exists  among  Surgeons  in  regard,  to  the  relative 
advantages  of  Circular  and  Flap  operations,  each 
having  its  zealous  advocates,  who  display  much 
energy  and  interest  in  the  controversy. 

The  advantages  claimed  for  the  Circular  mode 
are  as  follows  : 

1.  Cicatrization  is  more  rapidly  effected,  or  the 
wound  heals  quicker,  while  there  is  less  suppura- 
tion and  sloughing. 

2.  The  Arteries  can  be  more  rapidly  secured 
and  firmly  tied,  because  evenly  divided;  while 
there  is  no  danger  of  transfixing  the'm,  as  in  Flap 
operations. 

:>.  The  wound  can  be  more  readily,  efficiently 
and  .continuously  closed  with  sutures,  so  that  the 
water   dressings  may  be  employed  to  greater  ad. 
vantage    than  where  Adhesive   Piaster  is    exten- 
sively  used. 

4.  The  Vessels  contract  more  firmly,  thus  to  a 

[This  is  an  instrument   invented  by  M.  Chaissaignac,  tl 
part  of  which  is  a  sort  of  blunl   chain  ti  a     crew   or   i>\ 

a  rack  an  J  by  pinion.     The  notion  of  the  instrument  though  slower 
than  thai  of  the  knife,  is  more  rapid  than  that  of  the  ligature, 
its  influence  is  direct.     Ii   lir  t  com  L  then 'dividi    thi 

with  extreme  reeularit v. 


108  CIRCULAR  AND  FLAP  OPERATIONS.. 

considerable  extent  obviating  the  danger  of  secon- 
dary Hemorrhage. 

5.  Patients  can  be  more  safely  transported. 
Macleod  affirms  that  Flaps  are  knocked  about  in 
such  a  manner  as  to  bruise  and  injure  them  se- 
verely,— causiug  sloughing  and  materially  retard- 
ing recovery  when  Patients  are  carried  a  long  dis- 
tance either  by  land  or  sea. 

G.  Operations  can  be  performed  at  a  greater 
distance  from  the  trunk. 

The  advantages  claimed  for  the  Flap  operation 
are  : 

1.  The  operation  can  be  more  readily  and  rap- 
idly performed. 

2.  There  is  less  danger  of  having  the  bone  uncov- 
ered, and  of  thus  exposing  the  operator  to  ridi- 
cule, and  the  Patient  to  additional  suffering. 

3.  The  Surgeon  is  enabled  to  select  a  covering 
for  the  bone  from  some  of  the  tissues  which  re- 
main intact. 

4.  The  muscles  can  be  more  readily  retracted, 
and  the  saw  more  advantagiously  used. 

5..  The  stump  is  usually  better  covered,  though 
the  work  of  cicatrization  may  be  delayed.  Union 
by  "first  intention"  frequently  takes  place  in  this 
connexion,  the  opinions  of  some  to  the  contrary 
notwithstanding. 

With  this  statement  of  the  arguments  advanced 
upon  both  sides  of  this  long  mooted  question,  the 
Surgeon  is  left  to  his  own  judgment  in  regard  to 
the  the  cases  which  may  present  themselves,  as  no 
specific  rule  can  be  given  which  will  apply  to  each 
individual  injury,  and  as  the  best  Surgeons  vary 


LENGTH  OF  FLAP.  109 

their  operations  according  to  the  nature  of  the 
circumstances  surrounding  them. 

As  a  general  thing,  the  Double  Flap  operation 
willbe  found  best  adapted  to  single  bones,  as  the 
thigh  and  arm  ;  and  the  Circular  best  suited  to 
double  bones,  as  the  leg  and  forearm. 

Length  of  the  Flap. — Sir;  C.  Bell,  declares  that 
"  the  general  rule  in  all  cases  is  to  save  integu- 
ment enough  to  cover  the  muscle,  and  muscle 
enough  to  cover  the  Bone,  taking  care  to  scrape 
off  none  of  the  Periosteum."  This  is  capital  ad- 
vice and  should  be  regarded.  It  should  also  be 
borne  in  mind  that,  after  amputations  for  gun-shot 
wounds,  there  is  more  of  tonic  muscular  contrac- 
tion than  under  ordinary  circumstances ;  and 
hence,  greater  care  should  be  taken  to  see  that  the 
Bone  £s  properly  covered. 

Though  it  is  certainly  possible  to  have  the  • 
<>l  too  great  a  I  ngth,  yet  nothing  can  be  more  em- 
barrassing to  the  patient  and  annoying  to  the 
iSurgeon  than  to  have  them  too  short.  The  expo- 
sure and  exfoliation  of  the  Bone  ibllow,  as  a  mat- 
ter of  necessity,  and  another  operation  has  to  be 
performed,  as  the  only  means  of  correcting  the 
error.  A  mistake  of  this  kind  should  be  correct 
cd  as  soon  as  it  is  discovered,  even  before  the 
stump  is  dressed,  by  sawing  oil' another  portion  of 
the  Bone,  with  an  honest  acknowledgment  of  er. 
ror  on  the  part  of  the  Surgeon.  After  the  expi- 
ration of  a  few  days  only,  it  is  exceedingly  diffi- 
cult to  denude  the  Bone  sufficiently  to  apply 
the  saw,  as  it  immediately  bccomi  ted  with 

a  hard  and  irregular  callus. — defying   the   knife 


DOUBLE   FLAPS. 

and  rendering  its  exposure  a  veritable  work  of  ex- 
cavation. 

Let  the  Surgeon  remember,  however,  that  it  is 
not  so  much  the  length  of  the  Flaps  which  pre- 
vents the  risk  of  protrusion  of  the  Bone,  but  the 
height  at  which  it  (the  Bone)  is  divided  above  the 
angle  of  union  of  the  Flaps. 

Varieties  of  Double  Flap  Operations. — There  are 
two  varieties  of  this  mode  of  Amputation — viz: 
When  Anterior  'and  Posterior  flaps  are  made, 
and  when  covering  for  the  Bone  is  sought  for  on 
either  side  of  the  Limb  by  cutting  lateral  flaps. 
To  the  latter  method  a  serious  objection  can  be 
urged,  even  though  it  is  possible  to  save  some 
blood  by  cutting  the  Flap  which  contains  the 
artery  last,  the  Bone  is  prone  to  rise  np  in  the 
angle  between  the  two  Flaps,  and,  thus,  to  keep 
its  lower  end  continually  exposed.  The  same 
accident  may  occur  when  Anterior  and  Posterior 
incisions  have  been  made,  by  turning  the  Limb 
upon  its  side  instead  of  its  posterior  surface,  and 
thus  permitting  the  muscles  to  lift  the  lower  ex- 
tremity of  the  Bone  upwards  in  the  angle  between 
the  Flaps,  while  the  Flaps  themselves  are  per- 
mitted to  fall  downwards  by  the  force  of  their 
own  gravity.  Those  evils  can  be  avoided  by 
proper  watchfulness,  and  their  occurrence  is  con- 
sequently a  disgrace  to  the  Surgeon.  Let  him 
guard  against  a  protrusion  of  the  Bone  then,  as 
he  values  his  own  reputation,  not  that  such  acci- 
dents necessarily  imply  ignorance  or  carelessness? 
"but  as  they  are  thus  produced  in  a  large  majority 
of  eases,  an  amount  of  odium  attaches  to  them  and 


AMPUTATING    POINT.  Ill 

which  but  few  men  have  the  professional  status  to 
withstand. 

Whether  the  Flap  or  Circular  method  be  em- 
ployed, care  should  be  taken  to  calculate  the 
diameter  of  the  Limb,  and  to  give  the  skin  on 
either  side,  at  least  half  that  length.  The  Flaps 
may  even  be  a  little  longer  on  account  of  the  de- 
position of  the  skin  to  retract:  and  the  operation 
should  not  be  under-taken  until  the  length  to  be 
given  them  is  arranged  in  the  mind  of  the  Surgeon, 
and  the  precise  spot  at  which  the  Bone  is  to  he 
sawn  through,  accurately  determined. 

The  Point  at  which  Amputations  should  bb 
performed. — The  French  very  properly  distin- 
guish (1)  the  jriacc  of  necessity — where  {here  is  no 
choice  of  site  because  of  the  nature  of  the  injury — ; 
and  (2)  the  place  of  eh  ction  where  the  most  available 
locality  can  be  selected.  The  place  ofclc<'ti<>i>  varies 
in  different  members,  though  the  general  rule  is  to 
save  as  much  of  the  Limb  as  can  bo  done  without 
endangering  the  patient's  life.  The  facts  upon 
which  this  rUle  is  based  are,  the  greater  futility  of 
long  slumps  in  general,  and  the  dimunition  of  the 
danger  in  proportion  to  distance  from  the  trunk 
in  which  the  operation  is  performed.  Thus,  ac- 
cording to  Malgaigne,  from  26  Amputations  of  the 
smaller  toes.  1  death  occurred;  from  46  Amputa- 
tions of  the  great  toe,  7  deaths;  from  38  partial 
Amputations  of  the  toot,  '.»  deaths;  from  10-  Am- 
putations of  the  leg,  L06  deaths;  and  from  201 
Amputations  of   the    thigh    120    deaths.     In    the 


112  AMPUTATING    POINT. 

Crimea  the  mortality   after  Amputations  of  the 
Thigh  was ; 

for  lower  third  fifty  six  per  cent. 

for  middle  "      sixty  per  cent. 

for  upper    "      eighty  six  per  cent. 

for  Hip  one  hundred  per  cent. 

The  mortality  after  Amputations  of  the  Arm 
was: 

for  the  Fore-arm  seven  per  cent. 

for  the  Upper-arm  nine-teen  per  cent. 

for  the  Shoulder-joint   thirty-Jive  per  cent. 
These  facts  arc  significant,  and  should  be  care- 
fully garnered  as  the  most  reliable  data  upon  which 
the  Surgeon  can  base  his  judgments,  both  in  Field 
and  Hospital  service. 

Many  Surg-eons,  and  particularly  those  who  pre- 
fer the  Flap  operation,  are  in  the  habit  of  Ampu- 
tating the  Log  at  a  point  about  three  or  four  inches 
below  the  knee-joint,  as  the  operation  can  be  more 
conveniently  performed  there,  and  as  the  shorter 
stump  can  be  more  easily  managed  afterwards. 
Bockelof  Strasburg  has  however  collected  the 
statistics  furnished  by  various  authors  on  this  sub- 
ject, and  shown  that  the  mortality  attending  the 
higher  operation,  exceeds  that  of  the  lower — the 
Infra — Malleolar  operation, — 100  per  cent.  This 
he  attributes: 

1.  To  the  wound  being  farther  from  the  Body 
in  the  lower  operation. 

2.  To  the  surface  of  the  wound  being  smaller. 

3.  To  the  comparative  rare  occurrence  of  !' 
mia  and  Phlebitis. 

When  it  is  possible  to  obtain  artificial  limbs  of 


AMPUTATING  POINT.  113 

superior  construction,  much  greater  usefulness  of 
the  member  can  be  secured  after  the  supra-malleo- 
lar  amputation  has  l>ccu  performed;  but,  for  the 

attachment  of  the  "  wooden-leg,"  upon  which  our 
soldiers  must  rely  under  existing  circumstances, 
the  shorter  stump  is  for  more  available. 

The  rule,  enunciated  above,  is  not  however  of 
universal  application.  Amputations  through  joints 
arc  not  more  dangerous  than  operations  made  by 
section  of  the  bone;  and  hence,  a  portion  of 
a  member  particularly  if  a  small  one,  can  frequent- 
ly be  sacrificed  without  detriment,  to  secure  the 
advantages  of  a  disarticulation.  Thus  a  portion 
of  a  phalanx  may  he  sacrificed,  and  the  amputa- 
tion performed  at  the  nearest  joint,  rather  than 
wait  for  the  saw  ;  and,  notwithstanding  all  the  ad- 
vantages of  saving  an  inch  or  two  of  the  ulna,  and 
radius,  it  is  better  to  amputate  at  the  elbow  joint 
than  too  near  it,  in  order  to  avoid  the  disadvan- 
tages of  the  subsequent  inflammation.  The  same 
remarks  will  apply  to  amputations  made  at  a  short 
•  list a ncc  from  the  shoulder  and  knee  joints, J  but 
the  same  rule  does  not  hold  good  for  the  hip  joint, 
as  disarticulation  there  is  usually  fatal. 

Amputations  made  through  the  cancellous 
structures  near  the  ends  of  the  long  bones,  are  less 
dangerous  than  those  made  through  the  shafts,  as 
they  are  not  so  likely  to  be  followed  by  suppuration 
and  pyaemia. 


(Baud  that  his  experience  in  the  Crimea  fissures  him  thai 

disarticulation  ol  the  knee  should  always  be  ; 
of  the  I 


114  MANAGEMENT  AFTER   AMPUTATION. 

Management  after  Amputation. — As  was  men- 
tioned before,  the  success  of  an  Amputation  de- 
pends as  much  upon  the  subsequent  managemen- 
ofthe  case,  as  upon  the  mariner  in  which  the  opera 
tion  is  performed.  The  following  rules  should 
govern  the  Surgeon  in  this  regard. 

1.  Keep  the  wound  open  until  the  patient  has 
recovered  from  the  shock  of  the  operation  or  from 
the  effects  of  the  Chloroform,  lest  Arteries  which 
have  been  paralyzed  thereby,  may  bleed,  and 
endanger  the  patient's  life. 

2.  Adjust  the  Flaps  carefully,  but  not  too  closely, 
by  means  of  sutures,  and  strips  of  adhesive  or 
isinglass  plaster.  The  sutures  should  be  made  of 
strong  saddler's  silk  (or  silver  if  it  can  be  obtained,) 
and  applied  in  such  a  manner  as  to  embrace  at 
least  one  eighth  of  an  inch  of  the  upper  Flap,  and 
one  quarter  of  an  inch  of  the  lower. 

3.  Bring  out  the  Ligatures  at  one  angle  of  the 
wound  and  secure  them  by  a  small  strip  of  ad- 
hesive Plaster,  taking  care  to  handle  them  lightly 
and  to  provide  against  the  possibility  of  traction 
during  subsequent  manipulations. 

^.4.  The  wound  may  be  dressed  in  two  ways :  (1) 
By  inserting  sutures  at  the  distance  of  an  inch  from 
each  other,  supporting  them  with  strips  of  ad- 
hesive plaster,  then  using  a  single  layer  of  wet 
cloth,  covered  with  a  waxed  cloth  to  keep  in 
moisture,  and  applying  an  iced  bladder  or  water  by 
irrigation.  (2.)  Applying  sutures  to  the  entire  length 
of  the  wound,  drawing  the  intermediate  spaces 
together  by  means  of  Isinglass  Plaster,  leaving 
uncovered  the  angle  where  the  ligatures  escape,  so 


AFTER    TREATMENT.  115 

that  drainage  may  be  kept  up  -,  and  applying  the 
Maltese  Cross  by  moans  of  a  light  roller,  bo  aa  to 
assist  in  excluding  the  air  and  converting  the 
wound  into  a  subcutaneous  one  No  water  dread- 
ing is  used  and  the  stump  is  left  undisturbed. 
This  mode  of  dressing  is  particularly  applicable  to 
Circular  Operations,  where  the  skin  alone  forms 
the  Flap.  Diachylon  Plaster  is  more  irritating 
and  less  convenient  than  Isinglass  Plaster,  and 
should  not  be  used  in  this  connexion,  when  the 
latter  can  be  obtained. 

5.  It  is  particularly    important   to    insist    upon 
absolute  rest  about  the  tenth  or  twelveth  day  after 
the  Operation,  for  at  that  time  the   Ligature 
escaping  from  the  Arteries,  and  ther< 
secondary  hemorrhage,  which  is  always  a  dai 

ous  complication. 

6.  It  should  not  be  forgotten  that  a  large  ma 

of  the  patients  who  come  under  the  care  of  military 
Surgeons  have  been    exposed  to    the  debilitatiug 
influences  incident  to  Camp  and  Hospital  life,  am 
that  the  demand    for  nutritious   food,  stimulants. 
&c,  is  unusually  great.     Without    attempting  t( 
decide  the  much  mooted  question  in  regard  to  th< 
change  of  type  alleged  to  have  taken  place  in  the 
diseases  of  the  present  day.  it  is  only  nec< 
call  attention  to  the  fact  that  a  typhoid  tendency 
does  manifest  itself  in  connexion  wi'.b  the  systems 
of  our  soldiers  generally,  and  that  the  denial 
usually  for  a  supporting  plan  of  treatment. 

7.  Apply  no  bandages  after  Amputations  mil 

it  be  for  temporary  purposes  upon  the  deld,  or  a 
light  one  to  retain  the  proper  dressings. 


116  BONDAGES. 

Bandages  have  been  recommended  as  a  valuable 
means  of  arresting  muscular  contraction,  but  when 
it  is  remembered  that  the  opposing  force  exerted 
by  such  appliances  is  nothing  when  compared 
with  the  power  with  which  muscles  contract  when 
entirely  severed, .the  fallacy  of  this  proposition  is 
manifest. 

Again,  they  have  been  employed  to  prevent  in- 
voluntary muscular  twitching,  causing  the  stump 
to  start,  &c.  Experience  shows  and  physiology 
demonstrates  the  utter  impossibility  of  a  sufficient 
control  being  exercised  by  bandages  in  this  re- 
gard. 

And  finally,  it  is  asserted  that  they  prevent 
purulent  absorption,  as  well  as  the  entrance  of  air 
into  the  veins.  This  supposes  that  notwithstand- 
ing the  pressure  of  the  atmosphere,  veins  remain 
patulous  after  being  divided,  whereas  except,  un- 
der peculiar  circumstances,  they  immediately  close 
without  requiring  the  intervening  agency  of  ban- 
dages applied  to  the  stump.  Besides,  veins  have 
no  Such  power  of  suction  as  is  claimed  for  them 
under  this  hypothesis.  But  they  are  likewise  in- 
jurious by  complicating  the  dressings,  concealing 
the  stump  from  view,  becoming  offensive,  and  re- 
tarding the  flow  of  blood  to  a  part  which  requires 
as  much  of  that  vitalizing  and  recuperative  fluid 
as  its  capabilities  will  admit.  It  is  better  there- 
fore, to  support  the  limb  upon  a  pillow  and  employ 
cold  water  dressings  without  bandages,  save  such  as 
have  been  mentioned. 

Accidents  following  Amputation. — The  accidents 
which  supervene    upon  amputations   are    those 


NECROSIS    OF    BONE.  117 

winch  are  peculiar  to  the  operation  and  those 
which  pertain  to  it  in  common  with  wounds  gen- 
erally. The  most  prominent  of  those  which  are 
peculiar  to  the  operation  arc :  Necrosis  of  the 
bone  ;  Conical  Stump  ;  .Neuralgia  of  the  Stump 
and  Aneurismal  enlargement  of  the  Arteries. 
The  most  prominent  of  those  which  associate  them- 
Belves  with  this  operation  in  common  with  wounds 
generally,  arc  :  Maggots  in  the  wound,  Erysipelas: 
Gangrene;  rysemia;  Tetanus;  and  Hemorrhage. 
Necrosis  of  the  Bone. — It  happens  not  unfre- 
quently  that  Necrosis  of  the  .Bone  takes  place  after; 
amputation.  The  remote  causes  of  this  accident 
are  :  Scrofula,Syphilis,and  Cacectic  states  ofthesys. 
tem generally ;  whilethe  direct  or  immediate  caus- 
es are  exposure  of  the  bone  either  by  destruction  of 
the  periosteum  during  the  operation  or  inflamma" 
tion  of  it  afterwards.  The  signs  by  which  it  can  be 
determined  are  the  ordinary  symptoms  ot  local  in- 
flammation to  which  are  subsequently  superadded 
those  which  particularly  distinguish  the  progress  of 
that  morbid  process  in  bony  tissue — such  as  great 
pain  and  swelling,  red  and  glazed  condition  of  the 
surface,  the  copious  discharge  of  a  very  fceted  pus, 
&c,  the  formation  of  a  sequestrum,  <.v:c  The 
treatment  consists  in  endeavoring  to  cover  the  de- 
nuded bone,  in  sustaining  the  strength  of  the  pa- 
tient, and  in  exercising  the  affected  portion. 

Conical  Stumps. — The  hone  may  protrude  in 
consequence  either  of  the  carelessness  of  the  Sur- 
geon iu  not  leaving  covering  enough,  orof  the  un- 
avoidable retraction  of  the  tissues.  The  reader  is 
referred    to   what   has  already  been  said  in  regard 


118  CONICAL    STUMPS. 

to  the  length  of  the  flaps,  and  the  rules  for  cutting 
them. 

When  it  becomes  apparent  that  this  accident  is 
likely  to  occur,  the  following  procedure  may  be 
attempted  with  a  reasonable  hope  of  success  :  Out 
a  long  strip  of  adhesive  plaster  two  inches  and  a 
half  in  width  ;  apply  one  end  upon  the  inner  side 
of  the  limb,  beginning  if  possible,  eight  inches 
above  the  wound;  apply  the  other  end  upon  the 
other  side  of  the  limb  in  the  same  manner;  make 
a  few  turns  with  a  roller  wetted  or  a  strip  of  adhe- 
sive plaster,  around  the  limb  and  over  the  plaster 
tirst  applied ;  to  the  loop  ^formed  by  'the  tirst 
strip  of  adhesive  plaster,  formed  below  the  ampu- 
tated surface,  attach  a  small  cord;  then  pass  this 
cord  over  a  small  wheel  at  the  foot  of  the  bed,  and 
tie  to  it  a  weight  sufficiently  heavy  to  bring  the 
soft  parts  down  over  the  denuded  bone.  Traction 
may  be  kept  up  in  this  way  for  weeks,  without  in- 
convenience to  the  patient,  and  with  th«  best  re- 
sults. The  author  recalls  in  this  connexion  as  il- 
lustrative of  the  advantages  of  this  plan  of  treat- 
ment, the  case  of  Burns  of  the  Louisiana  Battalion 
ot  Tigers,  who  was  wounded  by  a  conical  ball  just 
above  the  ankle,  in  a  picket  tight  on  the  Potomac. 
Shortly  after  the  tirst  battle  of  Manassas,  he  was 
brought  to  the  General  Hospital  at  Charlottesville, 
Virginia,  and  placed  under  my  charge.  On  en- 
quiry 1  found  that  two  amputations  had  been  per-* 
formed  on  him, — one  below  the  knee  joint  and  the 
other  just  above  it,  the  second  being  necessitated 
by  the  protrusion  of  the  bones  from  the  stump. 
Notwithstanding  that  the  thigh  operation  had  evi- 


CONICAL    STUMPS.  119 

dently  beeu  performed  with  care,  the  bo**G  was 
protruding  fur  more  than  two  inches,  while  the 
muscle*  manifested  ;i  disposition  to  ooatraol 
farther.  An  effort  was  made  to  separate  the  aofl 
parts  from  the  bone  and  to  excise  it  at  a  propoi 
distance  above  the  surface  of  the  wound.  The  bone 
was  found  so  completely  surrounded  by  a  hard  and 
irregular  callus,  that  the  work  of  excavation  could 
not  be.  accomplished,  and  excision  was  consequent- 
ly made  on  a  plane  with  the  divided  tissues.  The  ad- 
hesive straps  were  then  applied,  as  before  described 
and  the  traction  continued  for  several  weeks,  at  the 
expiration  of  which  period  the  bone  had  been  com- 
pletely and  beautifully  covered.  The  principle 
involved  in  the  treatment  of  fracture  by  means  ox 
adhesive  strips  wassimpiy  invoked  in  a  new  direc- 
tion and  with  a  satisfactory  result. 

Neuralgia  of  the  Stump. — It  sometimes  hapj 
that  a  distinct  tuberose  enlargement  bjf  the  nerves 
in    the  stump  occurs,  attaining-  the  size  of  a   I 
cherry,  and  giving  great  pain  by  pressing  ag 
the  bone.     Excision  of  this  bulbous  extremity  ta 
tne  proper    remedy.      Again,    an  important  D 
may  be    included  in  one  of  the  ligatures, 
pain  and  paralysis.     The  stump  should  be  op 
and  the  end  of  the  nerve  cut  off.     [u  the  nor 
and  hysterical,  neuralgic  pain  frequently  ocC 
almost  defying  treatment.     As  general  r<   i 
tonics,   -cdatives  and   alteratives   may  be  adlll 
tered  ;  while ae  a  topical  application  tjiesul 
ous  injection  of  morphia  stands  unrivalled. 

Spasm  of  the  stump  must  be  treated  on  g 
principles     tonics,   nervous  atimulanl 


120  MAGGOTS  IN  WOUND. 

to  the  part,  &c,  are  the  most  approved  remedies. 
Aneurismal  enlargements  may  possibly  be  removed 
by  pressure;  but  if  of  a  more  serious  character  the 
Artery  must  be  ligated  or  another  amputation  at- 
tempted. 

Maggots  in  the  wound. — This  is  always  a  serious 
and  troublesome  complication — annoying  to   the 
patient  and  embarrassing  to  the  Surgeon.     Their 
tenacity  of  life  is    truly  astonishing,    while   the 
celerity  with  which  they  are   produced   is   truly 
wonderful.     A   wounded   surface   over    which   a 
seemingly   continuous    stream   of  cold  water   is 
flowing,   will  suddenly  and  almost   miraculously 
teem  with  these  active  and  disgusting  insects,  not- 
withstanding great  care  on  the  part  of  the  attend- 
ants.    Prevention,  however,  is  every  thing  in  this 
connexion.    If  the  stream  really  be  continuous,  and 
the     attention    unremitting,   the     accident    can- 
not occur.     When  these  insects  have  been  develop- 
heir  destruction  may  be  secured  by  either  one 
of  the  following   remedies:    calomel,  applied   in 
powder,    or   suspended   in    water;   black  wash; 
creosote  and  water;  an  infusion  of  the  marygold; 
chloroform:    elder   juice;    an   infusion    of    elder 
leav  owers ;  and  various  other  applications, 

■try  to  mention.     Calomel  and 
Elder  juice  are  the  most   reliable,  as  well   as   the 
harmless  of  these  various  remedies. 
Erysipelas. — This    affection   is    connected   with 
some  depraved  and  altered  condition  of  the  blood, 
icularly  of  the  red  corpuscles,  and  is  essential- 
ly the  local  manifestation  of  a  general  or  constitu- 
tional   malady.      It   is   really   a    disease    of    de- 


ERYSIPELAS.  121 

bility  in  as   much  as  the  nervoui    centres  are  not 

supplied  with  their  normal  and  m -ar\    amount 

of  healthy  pabulum,  in  consequence  the  precedent 
changes  in  their  vitalizing  fluid;     The  pathologi 
cal  conditions  which  characterize  this  disease  may 
be  thus  expressed. 

1.  Changes  in  the  blood,  whereby  the  .Corpuscle 
are  rendered  less  stimulant  and  nutritious  to   the 
nerve  centres,  &c. 

2.  Changes  in  the  nerve  centres  resulting  from 
the  absence  of  the  ssary  food,  whereby  they 
become  irritated  and  not  duly  stimulated. 

3.  Tn  consequence  of  this  irritation  the  whole 
system,  that  machinery  ofwhich  the  Centres  are  the 
motive  power — acts  irregularly;  and  hence  fever, 
local  congestions  and  inflammations,  disturbance  of 
the  secerning  organs,  &c,  ensue. 

4.  As  a  result  of  this  want  of  stimulation,  the 
centres  lose  their  tone,— their  generating  power 
abators,  and  the  whole  system  becomes  decidedly 
debilitated.     The    symptoms    which    distinguish 

is  are  so  well  known  as  scarcely  to  require 
enumeration.  They  are  the  following:  a  reddish 
flush  rapidly  spreading  over  the  surface;  a  peculiar 
stinging  and  burning  pain;  considerable  swelling; 
much  tension:  tenderness  on  pressure ;  great  heat  ; 
and.  tendency  to   effusion,   together   with  a   full, 

tent,  hut  weak  pulse;  a  dirty  and  coated  tongue; 
and   deranged    ^astro-intestinal  secretion.     There 

wo  principal  varieties,  viz:  the  simple  Cutane- 
ous and  the  Cellulo-Cutaueons  or  Phlegmonous. 
The  former  limits  itsell  to  the  skin,  while  the  latter 
extends  to  the  cellular  tissue  which  separates  that 


122  EKYSIPELAS 

tissue  from  the  muscles  and  the  muscles  from 
each  other.  The  phlegmonous  is  far  the  more 
serious  and  fatal  affection.  Its  symtoms  are  more 
violent  ah  initio,  while  a  tendency  to  rapid  and  ex- 
tensive suppuration  is  one  of  its  most  serious 
characteristics.  Beneath  its  hurried  and  fearful 
footsteps  muscles  are  uncovered,  blood  vessels  ex- 
posed, bones  robbed  of  their  covering,  joints 
opened,  and  whole  members  terribly  and  complete- 
ly devasted.  In  its  train  comes  Hectic  with  all  its 
frightful  retainers,  the  ghastly  herald  of  an  early 
death. 

When  suppuration  has  been  established,  and 
pus  is  evacuated  externally,  openings  are  formed 
bounded  by  edges  of  mortified  cellular  tissue,  and 
cicatrization  takes  place  most  tardily  if  at  all.  In 
many  instances  sloughs  of  great  extent  are  pro- 
duced, while  the  fever  continues,  the  general  dis- 
turbance augments,  an  intestinal  .inflammation  is 
excited,  prostration  ensues,  and  a  fatal  diarrhcea 
is  developed.  Occasionally  Erysipelas  is  primari- 
ly and  essentially  gangrenous,  marching  with  rap- 
id strides  to  a  fatal  termination,  and  utterly  defy- 
ing the  skill  of  the  Surgeon.  Eesearches  into 
the  pathological  anatomy  of  this  affection  clearly 
establish  that  the  inflammation  incident  to  it  af- 
fects in  different  degrees  the  skin,  the  tegumenta- 
ry  vessels,  the  cellular  tissue  and  the  lymphatic 
system,  and  that  its  fatality  and  violence  are  in 
proportion  to  the  depth  and  number  of  the  struc- 
tures involved. 

Without  discussing  ;it  length  the  question  of 
the  contagiousness  of  Kresipelas,  it  is  sufficient  to 


ERYSIPELAS'.  123 

remark  that  though  this  character  has  been  claim- 
ed for  it  by  Lawrence,  Arnold,  Willan  and  Erich- 
Ben,  a  large  majority  of  modern  potholOgists  total- 
ly and  emphatically  repudiate  the  idea.  The  case 
referred  to  by  Erichsen  and  quoted  by  Chisolm 
an  illustrative  of  its  contagiousness,  is  not  suffi- 
ciently conclusive  as  the  appearance  of  the  dis- 
ease, under  the  circumstances  alluded  to,  may 
have  been  a  mere  coincidence,  and  as  proof  equal- 
ly as  strong  can  be  adduced  in  support  Oi  the 
communicability  of  any  disease.  If  the  disease 
be  strictly  contagious,  in  the  ordinary  acceptance 
of  that  term,  why  were  only  the  .sick  attacked, 
while  the  physicians,  nurses  and  attendants  escap- 
ed? It  may  also  be  asked  in  the  same  connexion, 
why  it  does  not  ''spread"  in  all  Hospitals  alike, 
or  communicate  itsell  to  those  who  dwell  in  their 
immediate  vicinity,  and  who  arc  in  communica- 
tion with  patients  suffering  from  the  disease  ? 

The  circumstances  which  associate  themselves 
with  the  development  of  Erysipelas  are  : 

1.  A  system  which  has  been  debilitated  by  pre- 
vious exposure,  fatigue,  loss  of  blood,  indulgence 
inveucry  and  intemperance,  or  improper  food. 

J.  Certain  special  hygienic  conditions, — such  a- 
deprive  the  patient  of  those  surroundings  which 
are  essential  to  the  preservaiou  of  his  system 
in  its  normal  stain*.-  -Among  these  are  impure 
air,  want  of  cleanliness,  non-nutritious  food,  ab- 
normal electrical  conditions  of  of  the  atmosphere, 
&c. 

These  circumstances  may  so  combiue  as  to  de- 
velop the  disease  spontaneously,  or  they  may  fur- 


124  ERYSIPELAS. 

nish  those  conditions  which  necessitate  its  dissemi- 
nation when  the  morbific  elements   are  furnished 
by  a  case  already  existing,  as   occurred  in  the  in- 
stance  alluded   to  by  Erichsen;  but  it  cannot  be 
pretended  that  without  these  particular  conditions 
— this  special  preparation  of  the  system  for  the  in- 
vasion of  the  malady — erysipelas  can  be  propagated 
by  contract.     By  a  "  contagious   disease,"  accord- 
ing to  the  teachings  of  the  ablest  writers,  is  meant 
an    affection   which  under  ordinary  circumstances, 
and   with   the   human  system  in  its  normal  condi- 
tion,   attacks  a   large  majority   of  those  who  are 
brought    in   contact  with  it.     Erysipelas  does  not 
thus  propagate  itself  save  under  extraordinary  cir- 
cumstances, and  when  the  normal  status  of  the  sys- 
tem has  been  materially  altered ;  and  hence  a  pri- 
ori, it  is  not  a  "contagious  disease  "  according  to 
the  usual  acceptation   of  that   term.     A   malady 
which  is  not  "  contagious  "  cannot  be  "  infectious,'' 
inasmuch  as  the  latter  term  implies  propagation  by 
contact  with  some  emanation — atrial  or  gaseous  it 
may  be — from  an  affected  system. 

The  treatment  of  erysipelas  has  become  far  more 
rational  and  successsful  within  a  few  years.  The 
seeming  violence  of  the  febrile  phenomena,  is  no 
longer  regarded  as  an  indication  for  antiphlogistic 
remedies ;  but,  regarding  it  as  essentially  and  ex- 
clusively a  disease  of  debility,  the  profession  has 
learned  to  depend  upon  tonics  and  stimulants,  as 
the  agents  best  calculated  to  stay  its  rapid  and  fear- 
ful progress. 

So,  likewise,  the  doctrines  of  Higginbottom,  in 
regard  to  the  pathology  of  the  disease,  have  been 


ERYSIPELAS.  125 

overturned  by  the  more  enlightened  views  of  Cho- 
rncl,  Blanche  and  Biett,  and  it  is  now  recognized 
and  heated  an  a  constitutional  disease  which  ex- 
presses itself  in  a  topical  inflammation. 

The  primary  indications  arc  to  administer  reme- 
dies which  will  restore  the  altered  corpuscles  to  their 
original  purity,  and  at  the  same  time  give  tone  and 
power  to  the  exhausted  nerve  centres.  Muriated 
Tincture  of  Iron  and  Sulphate  of  Quinine  arc  the 
remedies  which  will  most  successfully  accomplish 
these  results  £and  the  following  prescription  will 
host  combine  them: 

ft  Tinct:  Muriatici  Ferri,         5iij- 
Quinite  Sulph  :  ►)  ij. 

A«]iia,  font  g  iv 

M 
S. — A  teaspoon ful  every  third  hour. 

The  Muriated  Tincture  of  Iron  is  not  only  more 
rapidly  absorbed,  but  it  also  possesses  the  power  of 
restoring  the  altered  corpuscles  and  of  controlling 
the  local  inflammation,  byconstringingthe  capilla- 
ries of  the  affected  structures.  The  Quinine  acts 
directly  upon  the  the  nerve  centres  increasing  their 
capacity  for  the  production  of  that  subtle  nervous 
influence  upon  which  tho  integrity  of  the  whole 
organism  depends. 

Stimulants  should -also  bo  employed  for  the  pur- 
pose of  giving  tone  and  strength  to  the  exhausted 
system;  while  liquid  and  nutritious  food  consti- 
tute a  necessary  and  most  important  addition  to 
tho  treatment. 

Should  the  progress  of  the  disease  be  complica- 
ted with  gastric  disturbance,  au  emetic  or  a  mild 


126  ERYSIPELAS. 

purgative  should  be  administered,  for  the  purpose 
of  removing  all  offending  matters,  and  of  restoring 
the  secretions,  but  not  with  reference  to  its  deple- 
tory effects. 

Local  applications  are  neither  to  be  despised  nor 
too  much  relied  upon.  Mercurial  ointment,  as  re- 
commended by  Ricord,  the  Camphor  "Water  of 
Malgaigne,  Velpeau's  Ointment  of  Sulph:  Iron, 
Nitrate  of  Silver  as  proposed  by  Iligginbottom,  fo- 
mentations of  elder  flowers,  poppy  heads,  cranber- 
ries, hops,  &c,  solutions  of  nitrate  of  potash,  sugar 
of  lead,  carbonate  of  soda,  and  chlorate  of  potash- 
creosote,  collodion,  ice,  tincture  of  lobelia,  dilute 
acetic  acid,  white  lead,  muriated  tincture  of  iron 
olive  oil,  &c,  &c,  have  all  been  tried,  and  have 
their  admirers.  The  great  remedy  however  is  Cold 
Water  medicated  according  to  the  indication,  and 
applied  in  conformity  with  the  rules  and  principles 
enunciated  in  the  first  chapter  of  this  work.  Scai- 
rifications,  both  as  a  means  of  relieving  the  local 
hyperemia  and  of  permitting  the  escape  of  pus 
are  invaluable. 

It,  of  course,  becomes  a  matter  of  the  greatest 
moment  to  improve  the  sanitary  condition  both  of 
the  patient  himself,  and  of  those  with  whom  he 
may  be  associated.  It  is  well,  therefore,  to  place 
the  patient  in  a  tent  in  the 'open  air,  removed  from 
his  companions,  and  so  situated  that  he  may  get 
an  abundant  supply  of  fresh  air.  His  body  should 
at  the  same  time  be  kept  clean,  and  an  abundant 
supply  of  good  food  furnished. 

The  greatest  care  should  be  immediately  taken 
to  ventilate,  and  purify  the  Hospital,  to  see  that 


PYEMIA.  127 

wounde  are  frequently  and  properly  dressed,  and 
their  products  removed,  to  have  all  vessels  cleans- 
ed as  soon  as  they  are  us^d,  to  keep  the  bed  linen 
fresh  and  clean,  to  empty  the  spit  boxes  regular- 
ly, to  provide  pure  and  nutritious  food,  to  admin- 
ister stimulants  freely,  to  cheer  and  console  the 
patients,  to  segregate  the  sick  and  wounded,  to 
till  up  sinks  and  change  the  location  of  privies, 
and  to  do  such  other  things  as  the  laws  of  health 
require.  An  Epidemic  of  Erysipelas  is  not  likely 
to  prevail  if  the  hygienic  conditions  are  good,  and 
when  they  are  so,  the  separation  of  sporadic  casts 
no  longer  becomes  a  necessity. 

Pyaemia — By  this  term  is  meant  that  pus  poison- 
ing which  sometimes  takes  place  in  connexion 
with  wounds  produced  Jby  the  amputating  knife 
and  other  causes.  It  is  preceded  by  a  stage  of 
incubation  in  which  the  patient  is  restless,  sleep- 
less, uncomfortable,  feverish,  pale,  and  appre- 
hensive of  evil.  The  disease  proper  is  ushered  in 
by  violent  rigors,  which  continue  to  occur  at  regu- 
lar or  irregular  intervals,  followed  by  high  fever' 
jaundiced  hue  of  the  skin  and  conjunctiva,  a  furred 
tongue,  a  frequent  but  feeble  pulse,  delirium  or 
coma,  gastric  irritation,  diarrhoea,  sardonic  coun- 
tenance, great  thirst,  copious  sweats,  and  extreme 
restlessness.  The  patient  gradually  grows  more 
feeble,  the  joints  inflame  and  swell,  the  organs 
generally  show  greater  signs  of  disturbance,  the 
pulse  sinks,  collections  of  pus  occur  in  the  various 
tissues,  and  the  wound  frequently  becomes  boggy 
and  yielding  but  comparatively  dry,  and  death 
finally  closes  the  scene. 


128  PYEMIA. 

These  symptoms  are  manifestly  due  to  the 
presence  of  pus  in  the  blood — poisoning  that  fluid 
and  acting  as  an  irritant  to  the  tissues  and  organs 
generally.  The  purulent  fluid  is  introduced  into 
the  circulation  in  two  ways,  which  are  entirely 
distinct  from  each  other — viz: 

1.  By  inflammation  and  finally  suppuration  of 
the  internal  coats  of  the  Veins. 

2.  By  the  absorption  of  pus, — modified  but  not 
improved — into  the  blood. 

The  Blood,  as  previously  stated,  is  poisoned  by 
the  presence  of  this  product  to  such  an  extent,  that 
it  not  only  fails  to  supply  pabulum  to  the  tissues, 
but  becomes  positively  irritating  to  them.  There 
are  consequently  developed  in  various  parts  of  the 
body  points  of  irritation  at  which  the  blood  accu 
mulates  until  inflammation  is  developed,  and  an 
effusion  of  lymph  takes  place.  This  lymph  being 
but  poorly  organized  because  of  the  blight  im- 
pressed upon  the  whole  mass  of  the  blood,  readily 
and  rapidly  breaks  down  into  pus ;  and  hence  those 
multiple  abscesses  arc  formed  which  constitute  the 
most  prominent  feature  of  the  disease. 

Pyamiia  being  essentially  a  disease  of  debility, 
requires  to  be  treated  by  tonics,  stimulants,  and  a 
nutritious  diet.  The  restlessness  and  insomnia 
must  be  controlled  with  opium;  the  diarrhoea  with 
opium,  and  astringents  combiued ;  the  inflamma- 
tion of  the  veins  combatted  on  general  principles 
and  the  purulent  matter  given  a  free  vent. 
Macleod  suggests  the  propriety  of  ligating  the 
chief  vein  with  the  artery,  as  a  means  of  cutting  off 
the  channel  by  which  the  poison  is  couveyed  into 


I10SPITAL  OANGHENE.  120 

the  system.  This  may  prevent  the  absorption  of 
pus,  but  it  is  likely  to  defeat  its  own  object  by  in- 
ducimg  phlebitis.  Amputations  after  the  develop- 
ment of  Pyaemia,  so  far  as  the  authors  observations 
go,  arc  invariably  fatal.  The  application  of  Chlori- 
nated washes  to  the  surface  of  the  wound  will  be 
found  useful,  in  conjunction  with  the  general  treat- 
ment marked  out.  All  that  was  said  in  regard  to 
separating  the  patients  affected  with  this  malady, 
improving  general  and  individual  hygiene,  &c,  in 
connexion  with  Erysipelas,  applies  with  equal  force 
to  Pyaemia. 

Hospital  Gangrene. — This  is  also  a  disease  of 
debility,  and  results  from  the  influence  of  a  blood 
in  acting  on  an  enfeebled  constitution.  It  is 
both  contagious  and  infectious.  The  symptoms 
which  characterize  it  arc:  feverishness,  loss  of 
appetite,  sleeplessness,  coated  tongue  and  deranged 
bowels,  followed  by  a  dry  and  painful  condition  of 
the  wound,  the  appearance  of  an  ash  colored — 
Blough,  which  is  soft  and  pulpy,  engorgement  of 
the  neighbouring  skin,  eversion  and  undermining 
of  the  edges  of  the  wound — which  are  of  a  livid 
red  color — ,  and  finally  the  complete  breaking 
down  of  the  dying  tissue,  with  the  development  of 
a  thick  and  dirty  fluid,  and  a  peculiarly  offensive 
odour.  The  mortification  extends  rapidly  and  the 
system  sinks  under  its  baneful  influence.  The 
Jireatment  consist  taining  the   system   with 

tonic-  and  stimulants,  and  destroying  the  poisonous 
ichor,  from  which  the  local  ami  general  poisoning 
results.  The  first  indication  is  accomplished  by 
the  free  use  of   Quinine,  tron,  and  Brandy;   while 


130  TEtANtTS. 

the  second  is  fulfilled  by  sue*"",  remedies  as  the 
actual  cautery,  caustic  potash,  nit-ate  of  silver, 
tincture  of  iodine,  creosote,  chlon  'e  o  'von,  lemon 
juice,  pyroligneous  acid,  nitric  aciu,  mutiaticacid, 
&c,  followed  by  irrigation.  To  allay  pain,  calm 
nervous  disturbance,  insure  sleep,  &c. — Opium  may 
be  freely  used.  But  above  all  things  remove  the 
patient  from  the  infected  atmosphere ;  and  surround 
him  with  those  things  which  hygiene  and  humani- 
ty demand  for  his  health  and  comfort. 

Tetanus. — Tetanus  is  a  peculiar  condition  of  the 
nerves  centres,  characterized  by  the  following- 
phenomena;  the  wound  is  dry  and  painful;  the 
patient  shows  signs  of  mental  agitation  and  fright ; 
convulsive  movements  of  the  face,  and  of  the 
members,  particularly  of  the  arms,  take  place; 
deglutition  and  mastication  are  rendered  difficult — 
preceded  by  soreness  of  the  throat,  and  followed 
by  locking  of  the  jaws;  contraction  of  the  muscles 
of  the  neck  take  place;  the  abdominal  muscles  be- 
come hard  and  knotted  ;  violentand  repeated  spasms 
occur,  while  the  pulse  grows  feeble,  the  counten- 
ance sardonic,  and  the  skin  profusely  moist.  Tetan- 
us is  said  to  be  complete  when  all  the  muscles  of 
animal  life  are  equally  and  thoroughly  contracted. 
Under  these  circumstances,  the  body  becomes  so 
thoroughly  stiffened  as  to  seem  all  of  one  piece,  and 
wi  11  break  rather  than  bend — the  fingers  however  are 
an  exception  and  still  remain  flexible.  The  face  es- 
pecially is  remarkably  fixed  and  motionless,  and 
wearsan  expression  which  resembles  that  of  death  or 
of  mortal  agony.  The  pain  of  this  affection  is  terribly 
severe,  being  similar  to  that  produced  by  cramp  of 


TETANUS.  1S1 

the  muscles,  such  as  every  one  is  familiar  with.  The 
intellectual  faculties  remain  intact  up  to  within  a 
brief  interval  before  the  approach  of  death.  The 
appetite  is  good,  but  the  impossibility  of  degluti- 
tion frequently  produces  death  by  starvation,  ac" 
cording  to  Larrey. 

Tetanus  is  a  very  grave  malady  nearly  always; 
terminating  fatal  1}',  especial  ly  when  of  traumatic  or- 
igin, and  involving  all  the  muscles  of  animal  life. 

According  to  the  muscles  involved,  it  is  styled 
trismus,  emprosthotonos,  opisthotonos  and  pleu- 
risthotonos. 

It  is  essentially  a'  lesion  of  the  nerves,  but  as  yet 
pathology  has  not  ascertained  its  essential  nature, 
notwithstanding  the  recondite  researches  of  Bouil- 
laud,  Begin,  Andral  and  Magendie. 

The  theraputi.es  oi  tetanus  are  no  better  settled 
than  its  pathology.  Being  manifestly  a  disease  of 
debility,  it  is  a  matter  of  the  first  importance  to 
sustain  the  patient,  which  has  to  be  accomplished 
by  means  of  enemata,  on  account  of  the  difficulty 
of  deglutition. 

Cruveilhier  regarding  asphyxia  as  the  usual 
mode  of  death,  in  consequence  of  the  convulsive 
action  of  the  respiratory  muscles,  proposed  to  pre- 
ventthis  fatal  result  by  inducing  violent  but  vol'un_ 
tary  movement  of  the  same  muscles.  He  compelled 
his  patients  to  make  forced  and  profound  inspira- 
tions until  the  contractions  were  overcome. 

Busse  recommends  friction  with  alcoholic  tinc- 
ture of  belladonna,  particularly  over  those  points 
where  the  convulsive  rigidity  is  greatest. 


132  TETANUS. 

Larrey  cut  short  the  disease  in  its  forming  stage 
by  amputating  the  limb  or  dividing  the  nerve. 

Fournier  treated  the  disease  successfully  by 
means  of  sulphurous  baths,  and  Pare  testifies  to 
the  efficiency  of  the  same  practice. 

Chloroform  has  many  advocates ;  extract  of  Can- 
nabis indica,  opium,  belladonna,  woorara,  and  in 
fact  nearly  all  the  remedies  in  the  Pharmacopea 
have  been  recommended  and  successfully  used. 
No  specific  remedies  can  be  relied  on,  but  the  fol- 
lowing is  perhaps  the  best  plan  of  treatment : 

Empty  the  bowels,  by  means  of  scammony, 
aloes,  gamboge  or  croton  oil ;  divide  the  principal 
nerve  of  the  part ;  apply  warm  water  medicated 
with  opium  to  the  wound  ;  administer  chloroform 
freely  until  anaesthesia  is  induced  ;  and  inject  mor- 
phia subcutaneously,  either  immediately  over  the 
track  of  the  principle  or  in  close  proximity  to  the 
nervous  centres  which  seem  most  involved.  If  the 
strength  of  the  patient  can  be  supported  there  is 
some  prospect  of  a  favorable  termination.  Sleep 
is  absolutely  necessary  to  the  comfort  and  salva- 
tion of  the  patient.  Nothing  can  be  more  impor- 
tant than  to  remove  all  foreign  bodies  from  the 
track  of  the  wound,  and  to  use  such  remedies  as 
arc  calculated  to  relieve  the  local  inflammation. 

The  patient  should  be  made  as  comfortable  as 
possible,  quiet  enjoyed,  and  an  equable  temperature 
preserved.  The  experience  of  all  Surgeons  estab- 
lishes the  fact  that  changes  of  temperature  are 
prolific  sources  of  this  disease — a  circumstance 
which  should  be  remembered  botli  as  a  means  of 
preventing  and  curing  tetanus. 


SUTURES. 

Tetanus    is  either 
cording  to  the  mode  of  its  product! 

Hemorrhage. —  As  the  subje 
treated  of  at  lengl  !i  in  a  i 
necessary  to  consider  it  here. 

S    TURES— IN 

rhage  has  been  ai 
cidental  or  arl 

I 
union  between  them,  and  ;• 
means  of  sid  ether  r  i 

:  ral  wiles  Foi     he 

of  Sutures  shouh  dii 

1.  E.uter  the  needle  at,; 
distance   from    the  margin 
length  of  the  woun< 

2.  Have  the  points  of  perfo 

the  amounl  of  tissue  embraced  in  1 
of  sufficient  extent  to  close  the  p 
wrinkling. 

•  :.  relied    :; 

the  wound,  ;•  sufficient  number  mu 
make  the  line  of  union  complete, 
rule  ter   to  employ  r. 

sutures  and  fcli 

together  wil 

4.  The  knots  of  the  Ligat 
upon  the  upp 

be  affected   by  . 
only  modera 

5.  £  Id  be  remo 

sion  has  taken   pli  >1  all  ai  once,  bui 

pately  and  carefully. 
G 


134  SUTURES. 

6.  In  the  application  of  sutures  avoid  wound- 
ing nerves,  vessels,  serous  membranes  or  ten- 
dons. 

7.  Should  union  take  place  by  "  first  intention," 
the  sutures  may  be  removed  about  the  eighth 
day,  but  if  by  "second  intention,"  not  under  a 
month.  • 

Particular  sutures. — It  may  be  well  before 
advancing  farther,  to  consider  briefly  the  differ- 
ent varieties  of  sutures  employed  in  Surgery. 

1.  The  Interrupted  Suture. — This  is  formed  by 
passing  a  needle  and  thread,  through  the  skin  and 
subcutaneous  cellular  tissue  from  without  in- 
wards on  one  side,  and  from  ivithin,  outwards  on 
the  other,  fastening  the  ends  of  the  thread  togeth- 
er, and  cutting  them  off  close  to  the  wound. 

The  stitches  arc  proportioned  in  number  to  the 
extent  of  the  wound,  and  are  usually  inserted  at 
the  distance  of  an  inch  from  each  other.  This  is 
the  form  by  which  the  margins  of  wounds  made 
in  performing  amputations,  are  kept  together  with 
the  assistance  of  adhesive  straps. 

2.  Glover's  Suture. — This  differs  trom  the  last  in 
that  the  edges  of  the  wound  are  brought  togeth- 
er, and  the  needle  and  thread  passed  at  once 
through  both  of  them,  then  brought  over  to  the 
same  side,  and  passed,  again  through  both  edges, 
and  so  on  to  the  end  of  the  wound,  making  at 
each  stitch  a  loop  which  is  drawn  tight — precisely 
as  the  edges  of  a  glove  are  "whipped"  together. 
This  is  not  much  employed  at  the  present  time. 

3.  The  Quilled  Suture. — This  is  applied  in  the  same 
way  as  the  interrupted  Suture,  only  the  needles 


TURES.  135 

are  armed  with  double  threads,  so  that  one  of  the 
extremities  forms  a  loop.  All  the  stitches  being 
made  on  the.  same  line,  a  peice  of  quill  is  passed 
through  the  loops,  and  the  threads  on  the  other 
side  of  the  wound  are  separated  and  tied  over  a 
similar  bit  of  quill,  with  sufficient*  force  to  bring 
the  sides  of  the  wound  together,  and  to  keep  them 
there. 

4.  Twisted  Suture. — A  round,  and  straight  nee- 
dle of  gold  or  silver — or  a  common  pin  is  pushed 
through  the  edges  of  the  wound,  from  without  in- 
wards on  one  side,  and  from  it i thin  outwards  on 
the  other.  The  first  needle  being  thus  introduc- 
ed, a  thread  is  passed  under  it  on  either  side,  and 
sufficient  force  exerted  to  bring  the  edges  well 
together;  another  is  similarly  placed,  and  a  third, 
or  as  man;-  as  are  wanted.  Then  taking  the  ends 
of  the  thread  they  are  crossed  in  front  of  the  first 
needle,  and  brought  again  under  its  extremities, 
so  as  to  form  a  figure  of  eight,  repeated  four  or 
live  times.  They  are  then  passed  under  the  se- 
cond, and  similarly  twisted,  and  so  on  for  every 
needle  introduced.  When  the  last  turn  has  been 
made,  the  two  ends  are  tied  together  in  a  knot  or 
bow.  A  small  compress  of  lint  should  be  placed 
under  the  point  of  each  needle  to  prevent  it  from 
irritating  the  skin. 

Percy  long  since  recommended  lead  as  a  good 
materia]  for  Sutures,  but  experience  has  demon- 
strated that  silver  wire  is  incomparably  the  best 
mail  mch  a  purpose,  in  as  much  as  it  is  both 

exceedingly  ductile  and  particularly  non  irritating 
to  the  animal  tissues.     Physic  used  kid  skin  rolled 


136  SUTURES. 

into  small  cords.  Dr.  Simpson  of  Edinburg,  re- 
commends wire  made  of  gold,  platinum  or  copper 
as  a  substitute  for  the  ordinary  suture.  Br.  Eve 
has  employed,  with  the  same  end,  fibres  from  the 
sinews  of  the  deer.  When  they  are  to  remain  in 
position  for  a  long  period,  employ  Metallic  Sutures, 
particularly  those  made  of  silver  wire,  but  under 
ordinary  circumstances,  it  is  best  to  use  those  com- 
posed of  some  organic  material.  Thread  made  of 
silk,  flax  or  cotton  can  generally  be  found  by  Sur- 
geons every  where,  and  when  properly  waxed, 
possess  sufficient  pliancy  and  strength  for  all 
practical  purposes. 

Ihe  Glover's  Suture  generally  puckers  the  wound 
and  may  be  replaced  in  many  instances  by  the 
Interrupted;  the  Quilled  Suture  causes  the  bottom 
of  the  wound  to  unite  while  its  edges  remain  open  j 
and  the  Twisted  Suture  by  compressing  the  flesh 
only  at  certain  points  is  more  liable  to  cut 
through,  and  disengage  itself  prematurely  than 
the  others.  Experience  has  shown  that  Sutures 
made  of  animal  tissue  do  not  possess  any  decided 
advantages,  and  they  have  fallen  into  disuse. 


CHAPTER  III. 


PARTICULAR  AMPUTATIONS. 

Having  given  the  general  rules  which  govern 
Amputations,  it  now  becomes  important  to  describe 
in  detail  the  methods  of  procedure  in  individual 
operations. 

Amputations  of  the  Lower  Extremities. — Under 
this  head  are  included  Amputations  of  the  Foot, 
Ankle-joint,  Leg,  Knee,  Thigh,  aud  Hip-Joint. 

Amputation  of  the  Toes. — Directions :  Seize  the 
phalanx  firmly  and  bend  it  so  as  to  give  promin- 
ence to  the  joint;  make  an  incison  across  the  joint, 
cutting  well  into  it ;  divide  the  ligaments  carefully 
on  either  side;  and  then  cany  the  knife  through 
the  joint  and  cut  a  flap  from  the  under  surface  of 
the  toe.  The  flap  should  then  be  brought  over 
the  surface  of  the  disarticulated  joint  and  secured 
by  ligatures  or  adhesive  plaster.  The  toes  may 
be  amputated  at  the  second  joint  in  precisely  the 
same  manner. 

Amputation  of  ihc  Great  Toe  at  the  Meta-tarsal 
Articulation. — Directions :  Pass  a  narrow  bistoury 
up  oh  one  side  of  the  proximal  phalanx  as  high  as 
the  articulation;  carry  it  then  across  the  jointt 
turning  the  point  so  as  to  cut  the  ligaments  and 
open  the  articulation ;  lay  the  blade  flat  against 


138  AMPUTATIONS  OF  THE  TOES. 

the  toe  and  cut  out  a  flap  on  the  opposite  side. 
The  joint  really  lies  much  deeper  than  one  un- 
acquainted with  the  Anatomy  of  the  part  would 
suppose, — a  fact  which  should  be  remembered  in 
introducing  the  knife.  It  is  important  to  preserve 
the  distal  end  of  the  meta-tarsal  bone  so  as  to 
strengthen  the  foot  and  prevent  lameness.  The 
Meta-tarsal  bone  can  be  removed  by  an  operation 
similar  to  the  last, — the  first  cut  being  extended 
to  the  tarso — meta-tarso  articulation.  Avoid  the 
anterior  tibial  artery  in  opening  the  joint,  for  it 
dips  near  this  point  between  the  meta-tarsal  bones. 
There  is  always  danger  of  lameness  and  the  oper- 
ation should  be  avoided,  if  possible. 

Amputation  of  all  the  Toes  at  their  Meta-tarsal 
joints. — Directions:  Make  a  transverse  incision 
along  the  dorsal  aspect  of  the  meta-tarsal  bones; 
divide  the  tendons  and  lateral  ligaments  of  each 
joint  in  succession ;  dislocate  the  phalanges  up- 
wards ;  and  then,  placing  the  knife  between  the 
meta-tarsal  extremities,  cut  a  flap  from  the  skin  on 
the  plantar  surface,  sufficient  to  cover  the  heads  of 
the  exposed  bones.  Tie  the  arteries;  bring  the 
flap  in  position ;  and  lay  the  foot  on  its  outer  side 
so  as  to  facilitate  the  discharge  of  pus. 

Amputation  of  all  the  Meta-tarsal  Bones. — Direc- 
tions: Find  the  point  at  which  the  great  toe  arti- 
culates with  the  inner  cuneiform  bone  ;  make  a 
semilunar  incision  beginning  at  the  projection  of  the 
scaphoid  and  terminating  at  the  outer  side  of  the 
tuberosity  of  the  fifth  meta-tarsal  bone  ;  turn  the 
small  flap  thus  formed  backward,  pass  the  knife 
around  and  behind  the  projection  of  the  fifth  meta- 


AMPUTATIONS  01  OT. 

tarsal  bone,  so  as  to  divide   the    ligaments   which 
connect  it  with  the  cuboid  :  a  and 

cut  the  remaining  ligaments;    disarticulate   the 
third  and  fourth  meta-tarsal   bones;    then   a 
the  first  meta-tarsal  and  finally  the  second,  which 
being  locked  between  the  three  «  uneiform   bones 
is  difficult  to  dislodge  and  should 
in  some  instances.     All  live  bones  being  cl 
cany  the  knife  behind  them,  and  cut  a  flap  from  the 
sole  of  the  foot  of  sufficient  length  to  cover  tb 
posed  surfaces  of  the  disarticulated  bones.     Li 
the  Arteries;  bring  the  flaps  in  position,  and  keep 
the    foot  slightly  elevated.     This    is    known   as 
Lisfranc's  Operation. 

Instead  of  disarticulating,  the  bones  may  bo 
sawn  across,  a  little  in  advance  of  the  articulation 
as  proposed  by  Hey  and  Cloquet,  facilitating  the 
operation,  and  giving  results  equally  a 

Amputation  through  the  larsus. — Directions. — 
Find  the  the  joint  at  which  the  cuboid  articulates 
with,  the  os-caleis,   and  the  point  v  the 

scaphoid  articulates  with  the  astragalus ;  make  a 
semilunar  incision  acr<  >ss  the  front  of  the  foot  con- 
necting these  two  points;  turn  hack  the  anterior 
flap,  and  divide  the  ligaments  which  connect  the 
four  bones  mentioned  above  ;  then  pass  the  n 
through  the  joint,  and  cut   a   long   f  \  the 

sole  of  the  foot.     Tie  the  dorsal  and  two  pla 
arteries;  round  oft"  the  be- 

fore  bringing  it   into   position  :  and 
care   during  the   cure,  to  have  tl 
muscles  completely  relaxed,  by  I  foot 


140  STATION  OP  THE  I 

h  i  fcs  outer  surface  over  a  pillow;     This  is  known 
''j opart's  operation. 

i  at  the  Anlde  Join'. — To  Syme  "be- 
long-; the  credit  of  having  elevated  this  operation 
to  its  proper  position  in  the  Surgery  of  the  pres- 
ent day.  Being!  Lgerous  than  amputation 
of  the  leg,  and  particularly  successful  as  to  its  i*e- 
6th  in  America  and  Europe,  it  is  now  re- 
eled with  great  favor  by  the 'profession. 

ections. — Make  a  curved  incision  across  tke 
ep,  from  one  malleolus  to  the  other;  make  a 
id  across  the  sole  of  the  foot;  dissect  up  the 
id  expose  the  joint;  disarticulate  the  os- 
galaswith  the  rest  of  the  foot;  and 
\  3  the  projections  of  l\c  malleolar  pro- 
ber with  ihe.  saw  or  forceps.     Should  the 
joint  it  involved,  a  slice  of  the  louver  end 

-.(1  iibrula  may  also  be  removed. 
•  It  to  dis  »'<•!    the    flap  at  the    heel; 
hoiilcl  be  taken   not   to   cut 
;;  it,   o    to  wound  the  posterior  tibial  ^re- 
operation is  a  great  improvement  on  the 
older   methods    of    disarticulating    at   the    ankle 
int. 

The  operation  of  Syme  has  been   modified  by 
Tyrogoft,  by  retaining  a  portion  of  the  Calcanc- 
um,  and  thus  imparting  greater  length  and  rotun- 
dity to  the  Stump.     Directions. — Make  a  curvi- 
linef!  ion  around  the  foot  in  iront;  make  a 

sond  incisipn  under  the  sole,  extending  from 
the  front,  of  one  malleolus  to  the  other;  dissect  up 
the  flap,  divide  the  different  ligaments  and  detach 


AMPUTATIONS  OF  THE  FOOT.  141 

the  astragalus  ;  apply  the  saw  just  behind  the  as- 
tragalus and  divide  the  anterior  portion  of  the 
caloaneum ;  remove  the  malleolar  projections  to- 
gether with  a  thin  layer  of  the  extremity  of  the 
tibia ;  tie  the  vessels  and  bring  the  flaps  aceurate- 
ly  together.  The  advantages  of  this  operation  are 
that  a  larger  and  better  stump  is  secured,  there  is 
less  danger  of  wounding  the  posterior  tibial  arte. 
ry,  and  the  posterior  flap  is  not  so  liable  to  form  a 
pouch  for  the  accumulation  of  pus. 

Remarks. — These  operations  are  undertaken 
with  a  view  of  saving  as  much  of  the  foot  as  pos- 
sible, in  order  that  greater  support  and  a  more 
convenient  stump  may  be  secured;  and  though  in 
proper  hands  they  constitute  the  most  valuable  and 
scientific  of  Surgical  measures,  they  should  never 
be  undertaken  without  a  knowledge  of  the  anato. 
my  of  the  parts,  and  an  acquaintance  with  the 
rules  which  have  jurat  been  enunciated.  Either 
Lisfranc's  or  Iley's  operation  is  preferable  to  Cho- 
part's  or  Syme's,  when  admissible,  in  consequence 
of  affording  a  greater  length  of  Foot  and  securing 
a  less  tender  stump,  Pancoast's  proposition  to  sev- 
er the  Tendo  Achillis,  is  a  goodpne.  Syme's  op- 
eration does  better  for  chronic  diseases  of  the  foot 
than  when  made  lor  traumatic  lesions.  PyrogofFa 
modification  is  liable  to  the  same  criticism,  though 
a  beautiful  operation  in  itself.  Malgaigne  in  his 
statistics  of  amputations  in  the  Hospitals  of  Paris 
found  the  mortality  after  the  removal  of  the  great 
toe  one  to  six;  and  after  the  removal  of  the  .-mail- 
er toes  one  to  twenty-six  ;  while  in  amputations 
of  the  foot  the  proportion  of  deaths  was  twenty- 
6b 


142  AMPUTATIONS  OP  THE  LEG. 

five  per  cent.  For  the  statistics  of  the  operations 
performed  upon  the  foot  in  Richmond  the  reader 
ia  referred  to  Table  "A"  of  the  appendix. 

Amputation  of  the  Leg. — Directions  for  the  Cir- 
cular Operation  :  Administer  Chloroform ;  bring 
the  Patient  down  upon  the  Table;  command  the 
Artery  either  by  applying  the  Tourniquet  to  the 
Femoral  Artery  or  compressing  that  vessel  against 
the  Pubes;  have  the  limb  well  supported  and  the 
skin  drawn  upwards ;  make  an  incision  through  the 
integuments  entirely  around  the  Leg;  dissect  up  the 
integuments  for  about  two  inches  or  tw3  inches  and 
a  half  and  turn  the  cuff  back;  and  then  divide  the 
muscles  clown  to  the  Bone.  This  being  done,  pass 
a  double  catline  between  the  Bones,  so  as  to  divide 
the  interosseous  membrane ;  and  then  having  drawn 
the  muscles  back  by  means  of  a  three  tailed  Re- 
+racter,  saw  through  the  tibia  and  fibula — engag- 
ing it  in  the  larger  Bone  firmly  but  completing  the 
section  of  the  smaller  one  in  advance  of  the  other. 

Smooth  off  the  bony  surfaces  with  the  nippers ; 
lig-ate  the  Anterior  and  Posterior  Tibial  Arteries, 
and  such  branches  as  may  require  it;  and  dress 
the  stump  according  to  the  directions  previously 
given. 

Directions  for  the  Flap  Operation. — Place  the 
Patient  in  position  ;  administer  chloroform ;  bring 
the  limb  down  until  it  projects  well  over  the  lower 
edge  of  the  table;  ascertain  the  exact  locality  of 
the  bones  and  transfix  the  limb  by  passing  the 
knife  horizontally  behind  them,  and  not  between 
them ;  cut  a  flap  from  the  posterior  muscles  about 
five  inches  in  length ;  and,  then,  make  a  semilunar 


AMPUTATIONS  OF  THE  LE  143 

incision  across  the  anterior  face  of  the  Leg,  con. 
necting  the  two  points  at  which  tl  i  e  point  of  the  knife 
was  made  to  enter  and  to  leave  the  Limb.  After  this, 
dissect  back  the  anterior  Flap  slightly;  divide  the 
interosseous  muscle  and  ligament  with  a  double 
edged  catline  ;  use  the  retractor ;  and  saw  through 
the  bones,  as  previously  directed.  Mr.  Furgusson 
directs  that  the  Anterior  Flap  be  made  first,  by 
placing  the  Heel  of  the  Knife  on  the  side  of  the 
Limb  most  remote  from  the  Surgeon,  and  then 
drawing  it  aeross  in  front  of  the  Limb.  As  soon 
as  the  point  of  the  Knife  arrives  a.t  the  opposite 
side,  the  limb  must  be  transfixed  and  the  posterior 
Flap  made  as  above  described. 

See  that  the  bones  arc  of  equal  length  and 
that  their  edges  are  smoothed  off;  bring  the 
edges  accurately  and  evenly  to^etser ;  and  re- 
move the  spine  of  tho  tibia,  if  it  project  too  much. 

Remarks. — The  Flap  Operation  may  be  performed 
at  any  point  above  the  Aukle  Joint,  where  a  pos- 
terior flap  can  be  obtained,  though  the  rules  men- 
tioned above,  should  always  be  "borne  in  mind. 
Great  care  should  be  taken  not  to  push  the  knife  be- 
tween the  bones  or  transfix  the  main  artery;  never 
operate  above  the  tuberosity  of  the  tibia  le^ 
joint  be  opened  or  injured  by  the  subsequent  in- 
flammation ;  and  do  not  forget  to  shorten  the  rt 
Achillis  when  the  operation  i  med  near  the 

Ankle. 


144  AMPUTATIONS  AT  THE  KN1B  JOINT. 

STATISTICS. 

Pennsylvania           Hospital    69  operations,  mortality    42    percent. 

New  Yoak  "       102  '     "  "  84      "  " 

Massachusetts  "       23  "  "  21.7  "  " 

Reported  by  Malgaigne  "       192  "  "  56      "  " 

University  College                    14  "  "  14     "  " 

Reported  by  Mucleod                lol  "  "  SO.S  "  " 

"       by  Sorrell                  123  "  "  43. 9    "  " 

The  reader  is  referred  to  Table  "B"  of  the 
Appendix  tor  fuller  information  on  this  subject. 

Amputations  at  the  Knee  Joint. — Amputations  at 
this  joint  may  be  performed  in  two  ways  : 

1.  By  making  a  large  anterior  fiap  of  skin  and  a 
short  posterior  one  of  muscle. 

2.  By  making  a  short  flap  of  skin  in  front  and 
relying  upon  the  gastrocnemius  behind  for  a  flap  of 
sufficient  length  to  cover  the  joint. 

Directions  for  process  jNo  1. — Make  an  elipti- 
cal  incision  upon  the  anterior  and  lateral  surface 
of  fhe  limb,  from  the  centre  of  one  condyle  of  the 
femur  to  the  same  point  on  the  other  condyle* 
This  incision  must  have  its  convexity  downwards, 
and  should  embrace  surface  enough  to  cover  the 
joint  after  it  has  been  exposed.  Dissect  up  the 
flap  of  skin  just  made;  divide  anterior  ligaments 
and  open  the  joint;  then  divide  the  lateral  and 
posterior  ligaments  ;  and,  finally,  carry  the  knife 
behind  the  joint  and  cut  downwards  and  back- 
wards, making  a  short  flap  from  the  muscular  tis- 
sue on  the  posterior  aspect  of  the  leg.  This  being 
done,  retractand  saw  off  a  portion  of  the  condyles 
of  the  femur,  so  as  to  secure  a  smooth  surface 
over  which  to  adjust  the  flaps,  &c.  The  patella 
should  not  be  removed  in  the  operation. 

Directions  for  process  No.  2. — Between  the  same 
points,  i.  e.,  the  centre  of  the  condyles  make  an  elip- 


IMPUTATIONS  OP  TIIK  KNEE  JOINT.  145 

tical  incision  embracing  but  a  short  flap,  upon  the 
anterior  and  lateral  surfaces  of  the  limb;  divide 
the  ligaments  as  before  ;  and  ^finally  pass  tho 
knife  behind  the  disarticulated  extremities,  and 
cut  downwards  and  backwards,  making  a  suffi- 
cient l'  tp  of  the  muscular  tissue  behind  to  cover 
the  exposed  surface.  Then  retract,  and  saw  off 
condylesas  before.  ThePopliteal  with  itsbranches, 
the  inferior  articular,  middle  articular,  and  gamel- 
lar,  is  cut  in  this  operation,  and  should  be  imme- 
diately tied.  The  wound  is  closed  and  treated  in 
the  usual  manner. 

There  are  other  methods  of  performing  this  op- 
eration, but  the  plans  proposed  above,  will  be 
found  to  answer  sufficiently  well  for  all  practical 
purposes. 

Remarks. — The  propriety  of  amputating  at  this 
joint  has  been  much  questioned  by  Surgeons,  yet 
Velpeau,  Baudens,  Pancoast,  Malgaigne  and 
Macleod  have  all  declared  in  favor  of  it;  and  it 
may  be  resorted  to  in  connexion  both  with  prima- 
ry and  secondary  operations.  It  can  be  perform- 
ed very  expeditiously,  but,  there,  is  danger  of  sub- 
sequent inflammation,  and  perhaps  of  atardy  con- 
valescence. The  advantages  which  this  amputa- 
tion |  over  that  of  the  femur  may  be  thus 
summed  up : 

1-   The  shock  to  the  system  is  h 

2.  A  larger  and  more  available  sfump  is  secur- 
ed, while  it  is  less  liable  1"  ulceration. 

3.  A  false  leg  can  be  more  readily  attached,  and 
later  power  is  obtained  \'<>v  progression. 

4.  The  Medullary  ( 'anal  is  not  interfered  with,  and 


146  AMPUTATIONS  OF  TUB  KNEE  JOINT. 

the  extremity  of  the  femur  being  well  supplied  with 
Blood  Vessels,  there  is  less  danger  of  exfoliation. 

5.  The  Artery  being  in  the  centre  of  the  Flap 
and  but  few  ligations  being  required  in  the  opera- 
tion, there  is  less  danger  of  hemorrhage. 

6.  The  operation  is  not  so  fatal 'as  that  fpr  the 
fermur. 

STATISTICS. 


Reported  fey  Macleod, 

Operations 

8 

mortality    50.. 

t>er  cent. 

Reported  by  Smith, 

P 

86 

"             43 

~  11           41 

Reported  fey  Malgaigne, 

9 

"            77.* 
"             40 

(i      u 

Reported  by  Pager, 
Reported  fey  Sorrell. 

(( 

37 

CI          It 

.( 

2 

"          op' 

ii       it 

Mr.  Baudens  affirms  that  his  experience  in  the 
Crimea  convinces  him  that  disarticulation  of  the 
Knee  ought  always  to  be  preferred  to  amputation 
of  the  thigh,  raid  in  this  opinion  he  is  sustained 
by  Macleod  and  Malgaigne,  as  well  as  many  other 
Surgeons  of  the  highest  character  and  widest  ex- 
perience. 

Amputation  of  the  Thigh. — Directions  for  the  Cir- 
cular Operation. — Place  the  patient  upon  the  ampu- 
tating table;  administer  chloroform,  and  bring 
him  down  upon  the  tab-fe  until  the  wounded  leg 
projects  well  beyond  its  l^wer  margin — being  sup- 
ported at  the  knee  by  an  assistant.  Compress  the 
femoral  artery  either  by  tourniquet  or  digital  com. 
pression  against  ramus  of  pabes ;  direct  the  assistant 
to  seize  the  limb  with  both  hands  just  above  the 
point  selected  for  amputation,  and  to  draw  the 
skin  forcibly  back;  grasp  the  limb  with  left  hand 
so  as  to  steady  it ;  carry  the  hand  under  the  thigh, 
and  make  an  incision  at  one  sweep  completely 
round  the  limb  through  the  fat  down  to  the  fascia, 
dissect  up  the  skin,  &c,  about  two  inches  and  a 


AMPUTATIONS  OF  TIIE  THIGH.  147 

half;  and  having  turned  the  cuff  back,  with  one 
circular  sweep  of  the  knife,  divide  the  muscles 
down  to  the  bone.  This  being  done,  separate  the 
muscles  from  the  bone  for  the  space  of  about  an 
inch  ;  divide  the  periosteum ;  retract  the  flaps  • 
and  saw  through  the  bone.  In  cutting  through 
the  muscles,  it  is  a  matter  of  importance  to  turn 
the  edge  of  the  knife  towards  the  body  of  the  patient 
so  as  to  make  a  more  conical  flap.  Instead  ot 
dissecting  up  the  skin,  and  turning  it  back,  some 
Surgeons  simply  retiact  forcibly  after  the  first  in- 
cision has  been  made,  and,  then,  with  the  edge  of 
the  knife  turned  towards  the  patient's  body,  and 
the  retraction  continued,  cut  through  each  succes- 
sive layer  of  muscular  tissue  until  the  bone  is 
reached,  when  the  periosteum  is  divided  and  the 
bone  sawed  through,  as  described  above.  The 
arteries  should  then  be  ligated, — the  femoral  first, 
and  the  profunda  next,  if  it  be  cut,  and  all  pres- 
sure suddenly  removed,  so  as  to  encourage  hemor- 
rhage from  any  vessel  that  may  have  boon  over- 
looked. After  all  this  has  been  done  bring  the 
cut  edges  together  after  the  manner  already  point- 
ed out,  and  dress  the  stump  according  to  the  cir- 
cumstances of  the  case,  upon  the  plans  already 
discussed. 

Directions  for  Double  Flap  Operation. — Ad- 
minister Chloroform  ;  arrange  the  patient  upon 
the  table;  compress  the  main  artery  as  directed  in 
the  last  operation  ;  and,  then,  having  transfixed 
the  limb,  by  passing  the  knife  in  front  of  the  bone, 
and  as  near  to  it  as  p  issible,  cut  a  flap,  of  about 
five  inches  in  length,  from  the  anterior  portion  of 


148  AMPUTATIONS  OF  THE  THIGH. 

the  thigh.  This  being  accomplished,  insert  the 
knife  in  the  upper  portion  of  the  wound  depress  it 
and  transfix  the  limb,  by  passing  the  instrument 
behind  the  bone,  and,  then  cut  a  flap  from  the 
muscles  which  cover  the  posterior  portion  of  the 
thigh,  a  little  longer  than  the  anterior  flap.  Turn 
these  flaps  back ;  and,  having  cut  through  all  in- 
tervening tissue,  divide  the  Periosteum,  use  the 
retractor,  and  then  saw  through  the  bone.  Ligate 
the  Arteries,  bring  the  flaps  together,  and  dress  the 
wound. 

The  patient  should  then  be  removed  to  bed,  and 
the  stump  supported  on  a  pillow, — if  he  has  been 
brought  to  the  Hospital.  Should  the  operation  be 
peformed  at  afield  infirmary,  see  that  he  has  re- 
covered thoroughly  from  the  shock  of  the  opera- 
tion, and  the  effects  of  the  chloroform,  and  then, 
move  him  to  some  comfortable  position,  supporting 
the  stump  with  a  knapsack,  or  whatever  may  be 
convenient. 

As  before  remarked,  flaps  may  be  made  from  the 
inner  and  outer  side  of  the  limb,  by  transfixing  it 
from  above  downwards;  but  this  operation  is  ob- 
jectionable for  the  reason  that  the  bone  tilts  into 
the  upper  angle  if  the  wound  remains  uncovered. 
Remarks. — There  are  some  general  rules  which 
should  be  remembered  in  this  connexion. 

1.  Stand  on  the  outer  side  for  the  left  leg,  and  on 
the  inner  for  the  right — always  be  prepared  to  grasp 
the  limb  with  the  left  hand,  above  the  amputating 
point. 

2.  Arrest  hemorrhage  from  large  veins  by  elevat- 
ing the  stump,  and  compressing  with   the   finger ; 


AMPUTATIONS  OF  THE  THIGH.  149 

but  should  this  fail,  they  must  be  ligated.  Ooziug 
From  the  I  on  ma.3  be  invested  by  holding  a  com- 
press firmly  against  it  for  some  time. 

istinate  oozing  from  small  vessels. 

4.  Divide  the  bone  evenly,  and  use  the  bone  nip- 

10  render  its  surface  smooth  and  less-  irnta- 

I 

ul  not  to  include  nerves  in  the  liga- 
arteries. 

6.  Do  noi  pull  al  the  ligatures  until  about  the 
12th  flav,  le,<  Lary  hemorrhage  ensue. 

7.  Tbe  l-  '  should  remember,  as  a  cardinal 
prinei]  wer  an  operation  is  performed 
upon  the  thigh,  the  g\  re  the  chances  for  the 
patient's  recovery,  and  via  versa.  He  should,  in 
fact,  lot  only  :y  rg  inch,  but,  every  line,  sav- 
ed, a  tg  ;no  rial  advantage, — an 
advantage'  wh.ch  cannot  be  denied  to  the  object  of 

",  jeopardizing,  to  a  still 
of  the  patient. 

onstrates  the  advantage 

ns  of  the  thigh;  and  the  ab- 

ianees,    proper   means   of 

•  ■..  upon  the  battie  Held,  should 

inducement  to  postpone  the 

'ank  or  claims  of  the  suffer- 

iidiciouslyj  and  operate  speedily,  ifyou 

wish  ife  of  llio  patient.     Delay  is 

deatl  ii  may  be,  but  often  inevitable. 


150  AMPUTATIONS  0¥  TUE  THIGH. 

STATISTICS. 

Reported  from  University  College,  Operations  19  mortality  58  pr.  ct. 

"  by  Malgaigue,  "  .   40  "  75      '• 

"  'r  Soath,  "  24  "  100    '• 

"  "  Buel,  "  34  "  59.16" 

"  "  Norris,  "  4  "  00      " 

"  "  Maeleod,  "  161  "  64      " 

"  "  Mounicr,  "  46  "  82.6    " 

"  "  Sorrel  1,  "  172  "  59.8    " 

"  "  Sedillott,  "  '"  87.5    " 

'.'  "  Esmarch,  "  "  60       " 

"  li  Baundens,  l\  "  51      " 

"  "      Alcock.  "  "  CO      " 

Maeleod  after  giving  a  very  large  number  of 
cases  calculates  that  the  average  mortality  of 
Primary  Amputations  for  gunshot  wounds  alone, 
is  65.5  per  cent;  and  for  secondary  operations  the 
mortality  is  79.0  per  cent.  In  civil  Hospitals,  the 
mortality,  according  to  the  tables  furnished  by  that 
author,  is  for  Primary  Amputations  69.6,  and  for 
secondary  75.4.  The  per  centage  of  mortality  for 
secondary  Amputations  after  the  first  battle  of 
Manassas, — and  but  few  Primary  operations  were 
performed — greatly  exceeded  this ;  while  the  rela- 
tive success  of  the  two  varieties  of  Amputation  as 
indicated  by  operations  performed  in  connexion 
with  the  Richmond  Battles  is  much  more  decidedly 
in  favor  of  the  Primary  than  is  established  by  the 
records  of  other  fields. 

From  the  statistics  on  file  in  the  Surgeon  Gen- 
eral's office,  it  appears  that  there  were  performed 
in  and  around  Richmond,  from  June  lstto  August 
1st,  1862,  70  Primary  Amputations  upon  the  thigh, 
of  which  16  were  circular  and  10  flap,  and  44  not 
stated,  with  a  mortality  of  36.9  per  cent, — or  56.2 
for  the  circular  operations,  30  for  the  flap,  and  31.8 
for  those  not  stated ;  61  intermediate  amputations, 
of  which  9  were  circular,  6  flap,  and  46  not  stated, 


AMPUTATIONS  OF  THE  THIGH.  151 

with  a  mortality  of  80  per  cent, — or  66.6  for  the 
circular,  83.3  for  the  flap,  and  82.4  for  those  not 
stated;  and  41  secondary  amputations,  of  which 
7  were  circular,  2  Hap,  and  32  not  stated,  with  a 
mortality  of  88  per  cent, — or  42.2  for  the  circular, 
50  for  the  flap,  and  74.8  for  those  not  stated. — 
These  results  not  only  clearly  establish  the  impor- 
tance of  early  amputations,  but  plainly  show  that, 
as  regards  skill  in  the  performance  of  operations, 
and  success  in  subsequent  treatment,  the  Surgeons 
in  the  Confederacy  can  compare  most  favorably 
with  those  of  other  countries — a  fact  which  will 
become  all  the  more  patent  when  the  statistics  o* 
the  war  have  been  more  thoroughly  collected. — 
By  referring  to  the  appendix,  table  "  0,"  all  the 
facts  in  this  regard,  so  industriously  collected  and 
conveniently  arranged  by  Surgeon  Sorrell,  maybe 
more  accurately  understood. 

In  the  Crimea,  the  mortality  attending  amputa- 
tions made  in  the  various  "thirds"  of  the  thiirh 
was  materially  different.  Thus,  for  the  loirrr  Hard. 
it  was  fifty  six  per  cent;  for  the  middle^  sixty  per- 
cent;  and  for  the  ighty  six  per  cent.  The 
facts  which  may  be  gathered  from  all  of  these 
figures,  &c,  are  substantially  as  follows: 

1.  Amputation  of  the  thigh  is  always  a  serious 
thing. 

2.  Primary  Amputations, particularly  in  military 
Surgery,  are  more  fortunate  in  their  results,  by  far, 
than  secondary. 

3.  That  the  dan  a  unfavorable  result  in- 
creases for  every  inch  as  the  point  of  Amputation, 
approaches  the.  trunk,  being  greater  for  the  middle 


152  AMPUTATIONS  OF  THE  THIGH. 

third,  than  for  the  lower  third,  and  greater  still  for 
the  upper  third. 

Taking  all  things  into  the  account  however,  the 
rule  in  military  Snrgery  is  to  operate  at  once,  if 
the  patient  be  in  the  Field,  for  such  lesions  as 
were  indicated  in  chapter  second,  as  justifying 
Amputation,  since  it  is  impossible  to  secure  that 
tranquility  of  mind  and  body  which  is  essential  to 
the  salvation  of  the  limb.  In  Hospital  practice,  it 
is  well  to  folio  v  the  advice  of  Baudens,  and  to 
make  an  effort  to  save  the  limb,  if  the  wound  be 
in  the  upper  third, — where  to  amputate  is  death  in 
a  large  majority  of  cases. 

Amputation  on  the  Jlip  Joint. — Directions  for 
operating  after    the    manner    of  Liston. — Admin- 
ister chloroform  ;  bring  the  patient's  buttocks  to  the 
edge  of  the  table  ;  compress  the  antery  on  the  ramus  . 
of  the  pabes  ;  and,  having  inserted  the  long  catline, 
at  a  point  mid-way  between  the  trochanter  major, 
and  the  anterior  superior  spinous  process  of  the 
iliUm,  and  transfcred  the  limb,  cut  downwards  and 
then  forwards  so  as  to  form  the  anterior  flap.    Then 
turning  the  the  flap  back  disarticulate,  by  severing 
the  capsular  ligament  and  Ugamentiim-teres,  and  pass- 
ing the  knife  behind  the  joint,  make  the  posterior 
flap  by  cutting  downwards  and  backwards.     This  is 
the  operation  for  the  left  joint.     In  amputating  at 
the  right  joint,  the  knife  must  be  entered  on  the  in- 
ner side  of  the  limb,  just  opposite  the  scrotum,  and 
brought  out  at  a  point  midway  between  the  tro- 
chanter and  the  sup :  spin :  process   of  the  ilium, 
while  the  flaps  are  made  jnst  as  above  described. 
Direct  one  of  the  assistants  to  follow  the  knife  with 


AMPUTATIONS  OF  HIP  JOINT.  158 

his  right  hand,  as  the  anterior  flap  is  cut,  so  as  to 
seize  the  femoral  artery  when  divided.  Li  gate  the 
the  posterior  arteries  firsts  and  then  take  up  the  fem- 
oral, with  such  of  its  branches  as  bleed  too  freely> 
and  bring  the  flaps  together  in  the  usu<  I  way. 

The  operation  is  also  performed  by  making  two 
lateral  flaps,  one  on  (lie  vrmer  side,  of  the  adductor 
nmscles,  and  the  other  on  the  outer  side,  by  putting 
the  knife  over  the  trochanter  and  cutting  down- 
wards and  outwards.  The  inner  flap  is  usually 
made  JirsL  and  the  femoral  artery  tied  in  advr.nce — 
a  procedure,  however,  which  is  unnecessary  if  the 
assistant  be  reliable.  Some  Surgeons  prefer  ibis 
operation,  taking  care  to  cut  the  inner  flap  last 
in  order  to  avoid  severing  the  artery  until  the 
outer  flap  has  been  made  and  the  joint  disartic- 
ulated. 

Remarks. — This  amputation  can  be  rapidly  and 
readily  performed,  though  the  mortality  from  it  is 
very  great. — so  much  so  in  fact,  as  almost  to  exclude 
this  operation  from  the  legitimate  procedures  oi'Sur- 
gery.  When  the  limb  i>  wounded  high  in  the  wgper 
thirds  and  an  operation  seems  indispensable,  ii  is 
better  to  make  the  amputation  tihroagh  'he  trochan- 
ters  of  the  femur  than  atthe  joint,  ka  there  i 
danger  from  hemorrhage,  the  flaps  should  not  bo 
permanently  closed  for  soi  . — not  until  the  ef- 

of  the  chloroform  and  the  shock  have  entirely 
1  oil",  and  reacti<  l  hai  occurred.  Remember 
also  to  tie  the  ischiatic  and  gluteal  arteries,  in  the 
posterior  flap  before  ligating  the  femoral  and  pro- 
funda, for  if  the  main  artery  is  properly  held  by  the 
assistant,  it  will.  I.    Though  a  single  case  is 


154  AMPUTATIONS  OF  HIP  JOINT. 

on  record,  in  which  the  wv.  ad  thus  made,  healed  by 
■''  first  intention,"  union  doc  not  take  place  even  in 
the  most  favorable  cases  nnti  vfter  the  most  profuse 
and  exhausting  discharge  ot  j  is.  Various  modifi- 
cations of  the  amputation  at  the  u  .o-joint  have  been 
suggested  ;  but  the  one  described  is  incomparably 
the  best,  and  it  is  unnecessary  therefore  to  describe 
the  rest. 

Reported  by  Stephen  Srditn,  Operations    35,    Mortality   60     per  ct. 


"'•' 

STATISTICS 

rtcd  by  Stephen  Smith 

Operations 

35, 

Mortality   GO 

'•        "     Henry  .Smith, 

<t 

11 

"          27.3 

'        "    Legoue.st, 

u 

44, 

"          90.9 

'        "    Esmarch, 

(( 

7, 

"             99 

'        "    Macleod, 

u 

62, 

"          91.9 

'        "    Cox, 

:< 

84, 

"             75 

This  Table  includes  operations  for  disease  as  well 
as  injury,  a  fact  which  reduces  the  per  centage  of 
mortality  to  considerably  extent.  It  is  agreed 
among  military  Surgeons  that  when  performed  for 
gunshot  wounds,  the  mortality  is  over  90  per  cent — ■ 
thus  rendering  the  operation  so  difficult  as  to  make 
it  the  "ultissima  ratio"  of  our  science.  In  private 
practice  when  the  hygienic  condition  of  patients  is 
good,  and  the  proper  appliances  for  their  treatment 
are  available,  more  latitude  may  be  given  in  regard 
to  the  operation — though  it  is  always  an  exceeding- 
ly hazardous  one.  All  the  operations  of  this  char- 
acter, performed  by  the  English  Surgeons  in  the  Cri- 
mean war,  terminated  fatally,  either  from  shock  or 
hemorrhage,  or  the  conjoined  effects  of  both  of 
them. 


*  The  Author  knows  of  but  a  single  amputation  at  the  hip-joint 
which  has  been  performed  during- the  present  war — though  he  feeltj 
assured  there  have  been  others — a  secondary  one  performed  by  him- 
self, which  terminated  fatally.  He  has  heard  indirectly  of  severed 
others,   which  were   not  mon  til,  but  he  is  not  prepared    U? 

speak  with  confidence  in  regard  to  them. 


AMPUTATIONS  OF  TIIE  FINDERS.  155 

Amputations  of  the  Superior  Extremities. — It 

must  be  remembered  that,  in  injuries  of  the  upper 
extremities,  there  is  always  manifested  a  much  greater 
power  of  resistance  and  endurance  than  when 
the  lower  limbs  are  involved.  This  fact,  depends 
mainly  upon  the  greater  vascularity  of  these  parts, 
the  free  anastomosis  of  the  blood  vessels  and  the 
more  liberal  supply  of  nerves  in  the  arm  than  in  the 
leg,  and  should  warn  the  Surgeon  against  the  impro- 
priety of  sacrificing  the  one  for  injuries  which 
would  demand  the  immediate  condemnation  of  the 
other.  Amputation  of  the  upper  extremities  is, 
however,  frequently  a  surgical  necessity,  particular- 
ly since  the  introduction  of  conical  balls,  and  when, 
from  the  wounding  of  immense  numbers,  the  prop- 
er conservative  measures  cannot  be  adopted  in  order 
to  ensure  the  safety  of  the  limb. 

Amputation  of  tin  Fingers. — Amputation  of  Fin- 
gers at  the  second  or  the  last  joint,  should  be  per- 
formed precisely  in  accordance  with  the  directions 
given  for  the  amputation  of  the  toes  at  the  same 
points. 

Amputation  at  the  metacarpophalangeal  articula- 
tion- These  joints  belong  to  the  "Ball  and  Sock- 
et" variety — the  phalanx  furnishing  the  "ball"  and 
metacarpal  bone,  the  "socket."  Turn  to  directions 
for  amputating  a  single  toe,  and  all  the  rules  fortius 
operation,  will  be  found  in  detail.  It  is  only  neces- 
sary to  add,  that  after  the  fing<  r  has  been  separated 
from  the  hand,  the  head  of  the  metacarpal  bone 
should   be  invariably  rem<  as  to  give  more 

symmetry  and  u  j  to  the  member. 

The  thumb  may  be  amputated  in    precisely  the 


156  AMPUTATIONS  OF  THE  FINGERS. 

same  manner  as  the  fingers ;  but  it  ^s  matter  of 
great  moment  particularly  to  laboring  men,  to  save, 
it,  or  a  portion  at  least,  and  the  Surgeon  should  not 
remove  it,  in  its  entirity^  without  the  gravest  reas- 
ons. Its  metacarpal  bone  ma.  be  r<  moved  for  dis- 
ease or  injury,  and  the  phalan:  •  lehind,  with- 
out entirely  destroying  its  functions.  When  both 
metacarpal  bone  and  thumb  Lave  :  removed, 
the  operations  is  performed  in  thiswL  .  :  J  directions. 
— Carry  the  bistoury  through  the  soft  parts  between, 
that  of  the  metacarpal  hone  and  tjhat  of  the  ibi 
ger  until  it  is  arrested  b\  the  trapezium  above  ;  cut 
the  joint,  by  dividing  the  ligaments';  and,  then, 
the  knife  downwards,  forming  a  flap  of  the  fleshy 
substance  which  constitutes  the  bad  of  ilk  thumb. 

Am/putation  of  the  Four  Fingers  together. — Dircc 
tions. — Pronate  the   hand1  grasp    the  four  fingers., 
placing  your  thumb  on  the  joi 
and  your  index  on  that   of  the  index  fin  ger ;  then 
make   a   semi-circular  incision,   with  its  convexity 
downwards  from  the  inner  side      the  heat!  oj 
metacarpal  bone  to  the  outer  side  of  the  heat!  of  the 
second  metacarpal  bone.     This  being  don 
knife  overthe  four  joints,  so  as  to  destroy    lieir  dor- 
sal ligaments;  divide  each  lateral  ligament 
and  then  cut  through  the  palmar  ligaments.     L; 
slip   the  knife  under  the  end  of  the  p! 
cut  the  palmar  flap,  first  on  the  side  of  the  little 
finger,   following  exactly   its   palmar    create,    and 
raising  each    linger  in  turn,   to  follow  the   knife. 
These   are  the  proper  directions  for  the  right  hand  ; 
while  if  the  left  be  operated  on,  the  knife  must  pass 
in  a  different  direction,  that  is  from  the  index  to  the 


APUTATIONS  01"  THE  FTXe,  I 

little  finger.     When  the  operation  is  finished 
arteries.    If  they  bleed  freely  ;  unite  the  wound 
adhesive  straps;  and    place  the  hand  in- a  sling  i 
middle  position. 

DisarticulaMon  <>f  th<  four  fingers  at 
Metacarpo  articulation.  —  Direction-.-  -Proi 
hand,   and  grasp  the  joint   with   your   fir 
thumb;  make  a  semilunar  dap  on  the  dorsal 
of   tin-  hand,  from  one  side  to  the  other;  dividi 
space  betweon    the   finger  and    thumb  in 
length  ;  and    then    divide  all    the   do] 
transversely,   except    that  of  the  second  mi 
bone,  remembering  not  to  enter  the  joint.     All  I 
ligaments  being  divided,  as  well  as  the  intern:' 
external,   depress  the   metacarpus,    and  In.- 
bones:  finish  cutting  the  fibrous  bands  which  r< 
the  joint,  and  also  the  palmar  ligaments;  and.  I 
gliding   the   knife    under  the  pale  of 

bono,  cut  a  suitable    flap   from   it.     In  pi 
this  operation,  it  is  easj  to  remove  the  thumb,  ij 
cessary,  or  to    retain    it  with  either  th< 
tie  finger     n  li  icli  e\   n  alon<  are  of  g] 
When  the  operation  is  terminated,  it.on 
tie  the  trunks  of  the  radial  and  ulna  arteries,  a 
bringthe  Haps   together   wifh  adhesive  str 
roller  band:. 

It  is  a  matter  of  the  first  imp*  I  hat  the 

geon  Bhould  have  an    accurate  knowledge  of  th 
atomy   of  the    parte    in   performing  ation 

otherwise  he  will  be  compelled  to  aw   in  oi 

der   to  complete  it.     'MUe  terminal  points  of  the  line 
which    corresponds   with  the  direction  of 
should  be  ascertained  before  c  Lng  the 

7 


J 58  AMPUTATIONS  OF  THE  HAND. 

tion, — the  direction?  for  which  are  as  follows:— 
Run  your  finger  along  the  metacarpal  bone  of  the 
index  linger  until  the  point  is  reached  at  which  it  and 
the  second  metacarpal  bone  approach  each  other, 
and  the  former  unites  with  the  trapezoides, — this  is 
the  inner  termination  of  the  line  above  referred  to. 
Again,  trace  the  metacarpal  bone  of  the  little  finger 
upwards  until  a  cleft  is  reached  betweenjthe  os-mag- 
num  and  pisiform — a  little  in  advance  of  the  hitter 
— this  is  the  outer  terminal  point  sought  for.  The 
course  of  this  line  is  convex  with  its  inclination 
downwards  and  inwards.  ' 

Amputation  at  the  Radio  Carpal  Articulation. — 
The  first  thing  to  be  done  by  the  Surgeon  is  to 
distinguish  the  exact  seat  of  the  joint,  which  may- 
be determined  in  this  wise :  Draw  a  straight  line 
from  the  point  of  one  styloid  process  to  the  other, 
and  the  joint  will  be  found  in  the  direction  of  a 
eurve,  the  highest  point  of  which  passes  about  a 
quarter  of  an  inch  above  the  middle  of  the  straight 
line.  Directions  for  performing  the  double  flap  op- 
eration.— Grasp  the  wrist  so  as  to  compress  the  ulna 
and  radial  Arteries  and  semi-pronate  the  hand ; 
ma&e  a  semilunar  incision  posteriorly,  commencing 
half  an  inch  below  one  styloid  process  and  termina- 
ting ;it  the  same  distance  below  the  other ; — the  cen- 
tral portion  of  the  curve  being  two  inches  lower; 
dissect  up  this  flap  and  let  it  be  drawn  back  by  an 
assistant  ;  and,  then  divide  the  extensor  and  radial 
tendons,  the  capsular  ligament,  the  lateral  liga- 
ments, and  the  tendon  of  the  carpal  extensor.  Af- 
ter this  is  done  luxate  the  wrist,  pass  the  knife  be- 
hind it  and  cut  a  dap  from  the  anterior  surface,  one 


AMPUTATIONS  OF  THE  KTLM. 

inch  and  a  half  long.  fifosi  Surgeons  raise  the  had. 
die  of  the  knife  in  the  last  step  i  avoid  includ- 

ing the  pisiform  bone  in  the  flap,  but  this  is  unne- 
cessary, as  no  inconvenience  results  from  its  being 
left  with  the  skin,  while  the  attachment  of  the  Flex 
or  Carpi  Radialis  is,  in  tact,  preserved  there- 
by. The  radial  ai  d  ulna  arteries  are  now  to  be 
tied,  if  not  too  much  retracted;  the  integuments 
closed  by  adhesive  straps  and  a  roller  bandage 
lightly  applied  from  the  elbow  downwards. 

The  Circular  Methodumy  be  also  employed,  but 
the  above  process  is  preferable. 

vputajt/i<m  of  tJn  Ft>n  arm. — Surgically,  the 
fore  arm  is  divisible  into  three  portions,  viz  :  the  in- 
■/•,  which  is  flattened  and  well  suited  to  the  flap 
operation  ;  the  middle,  which  is  conical  and  favora- 
ble for  the  flap  operation, — as  it  is  difficult  to  turn 
the  cuff  of  skin  hack  ward  ;  and  the  upper  third, 
wjiich  is  round  and  muscular  and  suggestiv 
cither  the  flap,  circular  or  oral  pro 

Circular  method.  Directions. — Place  the  patient 
in  a  chair  or  upon  a  bed — the  latter  if  chloroform  is 
administered  : —  compress  the  brachial  artery  againsl 
the  humerus  by  means  of  a  tourniquet  or  the  fingers 
of  an  assistant ;  and,  then  partly  flex  the  fore  arm 
and  placeit  in  a  position  midway  between  pronation 
and  supination.  The  Surgeon  must  then  place  him- 
self so  a>  to  grasp  the  arm  above  the  point  of  am- 
putation with  Ins  left  hand,  and  proceed  to  operate 
according  to  the  directions  given  for  amputating  the 
leg  by  the  circular  or  the  OVal    method.      Apply  the 

upon  the  face  of  Jbotb  bones,  engage  the  ulna 
first  but  complex  i    more  firm- 


160  AMPUTATIONS  OF  THE  ARM. 

ly  connected  with  the  humerus;  The  ulria  and  rad- 
ial arteries  must  then  he  tied,  and  sometimes  the 
interosseous,  and  the  wound  closed  with  adhesive 
straps. 

Double  Flap  operation. — Directions. — Place  the 
arm  in  an  intermediate  position  between  pronation 
and  supination ;"  transfix  the  limb,  by  passing  the 
knife  either  from  the  ulna  or  the  radial  side,  in  front 
of  the  bone  ;  and  then  cut  an  anterior  Hap  mure  than 
two  inches  in  length,  from  the  muscles  on  that  side 
of  the  arm.  Carry  the  knife  to  the  opposite  side, 
and  transfix, — passing  the  instrument  in  at  one  an- 
gle of  the  previous  wound  and  bringing  it  out  at  the 
other  ; — and  cut  downwards  and  backwards  so  as  to 
form  the  posterior  flap.  Have  the  flaps  raised  by  ab 
assistant ;  cut  the  interosseous  ligament  and  remain- 
ing muscular  fibres ;  use  the  three  tailed  retractor ; 
and  saw  through  the  bones  in  the  manner  described 
above.     Dress  as  before. 

The  Single  Flap  operation  may  also  be  performed 
at  any  portion  of  the  arm. 

Amputation  at  the  ETbov)  Joint. — The  exact  posi- 
tion of  the  joint  may  be  ascertained  by  the  following 
method:  Find  the  internal  condyle  of  the  humerus, — 
this  is  three-quarters  af  an  inch  above  the  articulation 
of  the  humerus  with  the  ulna;  then,  seek  out  the 
external  condyle — this  is  about  half  an  inch  above  the 
articulation  of  the  humerus  with  the  radius. — 
These  tuberosities  being  on  the  same  plane,  it  follows 
that  the  articular  line  is  directed  from  within  ob- 
liquely outwards  and  upwards,  and  that  it  connects 
two  points,  <>ne  of  winch  is  three-fourths  of  an  inch 
"below  the  internaUuberosity  of  the  humerus,  and  the 


AMPUTATIONS  OF  THE  ARM.  161 

other  half  an  inch  below  the  outer  tuberosity.  The 
flap,  circular,  and  oval  operations  may  all  bo  per- 
formed. 

Tlif  Flap  operation  as  proposed  by  Dupuytren  is 
undoubtably  the  best,  even  though  several  Ligatures 
have  i"  be  used,  and  aome  of  the  first  Surgeons  pre- 
fer the  circular  method. 

Directions. — Supinate  and  partially  flex  the  arm: 
ascertain  the  position  of  the  inner  tuberosity  of  the 
humerus  ;  and,  having  grasped  the  soft  parts  imme- 
diately below,  pass  a  catline  through  the  muscular 
tissue  in  front  of  the  bones,  entering  it  about  one 
inch  below  the  epitrochlea,  and  bringing  it  out 
about  one-half  an  inch  below  the  epicondyle  :  and 
carry  the  knife  downwards  and  cut  a  flap  at  least 
four  inches  long,  from  the  muscular  tissue  on  the  an- 
terior face  of  the  fore  arm. 

Nexl  return  to  the  base  of  the  flap,  and  divide  all 
the  intermediate  tissues  by  a  semicircular  sweep  of 
the  knife,  down  to  the  joint  itself,  which  is  entered 
between  the  ulna  and  radius.  Then  divide  all  the 
ligaments;  dislocate  the  joint;  and  either  cut  oft' the 
olecranon  process  with  a  saw.  Or  pass  the  knife  he 
hind  it  and  remove  it  with  the  rest  of  the  hone. 

Ampliation  of  tlu  i>j>j"/  Arm. — The  circular, 
oval,  double  flap,  or  single  Hap  operation  may  be 
made,  though  the  circular  and  double  flap  are  most 
popular. 

Directions  for  the  Circular  Operation.-— Raise  the 
arm  almosl  at  a  righl  angle;  divide  the  skin  by  a 
circular  incision ;  retract  forcibly  and  divide  the  su* 
periiciai  fibres  of- the  muscles:  retract  again  forcibly 
and   divide  the  deeper  fibre-  down  to  the  bone:  de- 


162      AMPUTATIONS  AT  SHOULDER  JOINT. 

nude  the  bone  for  a  short  distance  upwards ;  and, 
then,  having  retracted  the  soft  parts  sufficiently, 
saw  through  the  bone.  Or,  again  the  integuments 
may  be  dissected  up,  and  turned  back  in  the  form  of 
a  cuff,  and  the  muscular  fibres  divided,  at  one  sweep 
down  to  the  bone  as  was  previously  described  in  con- 
nexion with  the  general  considerations  of  the  circu- 
lar mode  of  amputation. 

Tie  the  brachial  artery,  which  is  found  at  the  in- 
ner margin  of  the  biceps,  and  such  of  its  branches 
as  may  bleed  too  freely  ;  then  bring  the  wound  to- 
gether with  adhesive  straps,  and  unite  the  integu- 
ments in  an  oblique  direction. 

The  double  flap  operation  :  Directions, — Arrange 
all  the  preliminaries  as  for  the  previous  operation ; 
seize  the  limb  with  the  left  hand ;  transfix  it  anteri- 
orly ;  and  cut  a  flap  at  least  three  inches  in  length. 
Carry  the  knife  behind,  and  pass  it  through  the  arm 
at  the  upper  angles  of  the  previous  wound  ;  and  cut 
a  flap  slightly  longer  than  the  -first ;  pull  the  flaps 
back;  divide  all  the  tissues  to  the  bone;  retract  and  saw 
through  the  humerus.  Tie  the  brachial  artery  and 
its  branches,  and  bring  the  flaps  together  with  adhe- 
sive straps  and  suture-. 

Amputation  at  the  Shu  aide  i-  Joint. — There  are  sev- 
eral different  procedures  recommended  in  this  con- 
nexion, among  which  that  of  Larrey  is  incompara- 
bly the  best,  though  the  method  of  Lisfranc  has 
many  admirers.  Both  of  these  methods  will  be 
described  in  detail,  and  the  Surgeon  left  to  select 
that  one  which  he  deems  most  likely  to  meet  the 
presenting  indications. 

Directions-  for  performing  Larrey  V  Operation. — 


IMPUTATION   AT   SH01  LDER  JOINT.  163 

Compress  the  subclavian  artery  in  its  outer  portion, 
just  above  the  clavicle,  by  means  of  a  key  ;  and 
then  make  an  incision  from  the  border  of  the  acro- 
mion, to  one  inch  below  the  level  of  the  neck  of  the 
humerus — dividing  the  integuments  and  separating 
the  deltoid  into  two  equal  parts,  This  being  done, 
make  two  oblique  cnts,  from  thefirst  incision  on  either 
side,  and  terminating,  the  one  at  the  anterior  border  <>f 
the  axilla,  and  the  other,  at  its  posterior  border,  and 
both  prolonged  in  sueh  a  manner  as  to  divide  the 
tendons  of  the  pectoralis  major,  and  the  latissimus 
dorsi  near  ^heir  insertions  ;  divide  the  tissue  which 
retains  \\w<o  two  Haps,  down  to  the  bone;  and  draw 
them  back  so  as  to  expose  the  joint ;  cut  through 
the  capsule  and  tendons  above,  and  on  either  side ; 
dislecate  the  head  of  the  hon&  outwards,  by  carrying 
the  arm  transversely  across  the  body,  cither  for- 
wards or  backwards  :  pass  the  knife  behind  it, 
to  separate  it  completely  from  the  soft  partis;  and 
finish  the  operation  by  cutting  the  skin  and  toft 
parts  transversely,  and  on  a  level  with  the  inferior 
edges  of  the  oblique  incisions.  Tic  the  arteries,  be 
ginning  with  the  axillary,  and  bring  the  edges  of  the 
wound  together  with  straps  and  sutures.  This  des 
cription  is  long,  but  the  operation  itself  may  l>. 
ecuted  with  great  celerity  and  neatness. 

Directions  for  performing  Lisfranc's  operation, — 
slightly  modified.— Compress  the  artery  and  place 
the  patient  according  to  previous  direction ;  laj  hold 
of  the  arm  a  little  above  the  elbow  and  move  it 
from  the  side  and  slightly  backwards  so  as  to  give  .•> 
view  of  the  skin  in  the  Axilla;  then  push  a  long 
sharp  pointed_and  narrow  knife,  through  the  skin  in 


164  AMPUTATIONS  AT  SBOtJLDEK  JOINT. 

.the  arm  pit,  ;mimediatei)  in  front  of  the ■  tendons  of 
latissinlus,  dorsi   and   teres  major  muscles,  and 
ing  it  out  a  little  in  front  of  the  extremity  of  the 
nomion  process — taking  care  to  move  the  elbow 
outwards,  upwards  and  backwards^  as  the  thrust  is 
:  and  with  the  ami  in  this  attitude,  carry  the 
[tli  a  sawing  motion,  downwards,  backwards 
■■■    '\  outwards,  so  as  to  form  a  flap  at  least  fourinch- 
n  ..  of  the  posterior  portion  of  the  deltoid,  of 
tendons  of  the  lattissimus,  and  teres,  and  of  the 
■    in.     Raise  the  iiap  ;  divide  the  heads  of  the  mus- 
irrounding  the  joint :  carry  thefelbow  in  front 
the  chest  and  cut  through  the  capsular  ligament ; 
disarticulate;  and   then,  with    the  knife  passed  in 
>nt  of  the  bone,  form  another  flap  by  dividing  the 
muscles  and   integuments.     The  axillary  artery   is 
sd,  and,  to  prevent  hemorrhage,  an  assis- 
1  ould  grasp  the  soft  parts  of  the  axilla  at  this 

he      >eration. 
soon   as  the  limb  is  detached,  ligate  the  main 
:ther  with  the  circumflex,  subscapular,  and 
3  as   may   bleed  freely  :  then  bring 
in   apposition    and  confine  them  with  the 
pplia  tees,  taking  care  to  have  the  line  of  union 
• 
ratio]]  just  described,    is  for  the  left  limb, 
is  necessary  to  modify  it  for  thet'ight  bymak- 
3  first  flap  from  above,  downwards  and   back- 
.  Eiud,  then,  continuing,  as' directed   above. 
'•'. — in  operations  upon  the  band,  it  is  im" 
ve  as  many  finger  as   possible,    and 
thumb.     If  the  head  of  the  metacar- 
hv-nt'   be  not  removed,  when  a  linger  is  amputa" 


■  crsTids.  167 

apparent  in  connexion  with  this  operation.     Tim.. 
Guthrie  reports  L9  cases  of  secondary  amputations 
at  the  shoulder  with  a    mortality  of  L9,  and  10  ca 
es  of  primary  amputations  with  only  1  death.     Dr. 
Thompson,  in  giving  his  experience  after  the  Battle 
of  Waterloo,  states  that  almost  all  of  those  recovered 
who  had  undergone  primary  amputation  attheshoul- 
der  joint,  while  fully  one  half  died  of  those  on  whom  it 
became  necessary  to  operate  at  a  later  period.     Le- 
gist,  Gualla,   Smith,   Esmarch   and    Macleod  all 
agree,  thai   whereas,  the  mortality  attendant  upon 
primary  amputations  at  the  shoulder  joint  was  not 
more  than   38  per  rent,  the  mortality  following  se 
condary  amputation  whs  at  least  75  per  rent.     This 
operation  admits  ot  no  delay,  and  if  performed  at  all 
must  be  done  quickly  in  order  to  give  the  patienl  a 
chance  for  his  life. 

The  experience  of  modern  Surgery  has  demonstra- 
ted the  fad  that  resections  at  the  shoulder  joint  arc 
nol  only  safer  than  amputations,  but  may  take  the 
place  of  them  in  a  large  majority  of  cases, — thus 
preventing  greal  deformity,  and  securing  a  compar- 
atively useful  member.  This  subject  will  be  more, 
freely  considered  under  another  bead,  and  for  the 
present,  it  is  sufficient  to  say.  that  such  operation, 
have  been  attended  with  wonderful  success,  accord- 
ing to  the  testimony  of  Percy,  Baudens,  Legoust, 
Esmarch,  and  Macleod,  even  when  Beveral  inches  of 
the  shaft  of  the  humerus  had  been  destroyed. 

Amputations   at  the  shoulder  joint  have  been  fre 
quently  performed  by  Confederate  Surgeons  during 
the    present    war,  and  with  decided  success,  though 
sufficient    statistical  information   has    not    vet  been 


X'63  i  tfCs. 

rmine    the   relative  per  ccritage  of 
ality  which  has  aft  end  eel  the  operations  in  their 
hands. 

The  Shock  attending  amputation  at    this  articula- 
tion is  great,  and  should  always  be  provided  against 
by  a  liberal  allowance  of  brandy  or  whiskey,  before 
during  the  administration  of  the  chloroform. 
It   is   earnestly   to  be  hoped- that  the  Surgeons  of 
our  army  wil  not  content  themselves  simply  with  the 
.;  performance  of  amputations,  bat  that  they 
p    accurate   records    of  their  cases,  noting 
er  is  of  importance  connected  with  them,  es. 
•   the   relative  per  centage  of  mortality  for 
i(  rent   operations,  and  contributing,  of  their 
•    d    varied   experience,  something  at  leasl  I" 
e  advancement  and  perfection  of  the  science 
■   -     urge 

1    rof  operations   performed  in  Rich; 
mdnd  he  battles  of  the  "Seven  Pines"  and  the 

"  Se  "  the  reader  is  referred  to  Table  "  F  " 

idix  to  this  volume. 


REMARKS.  165 

i*po-phalangeal  joint,  there  w  ill  al. 

be  deformity,  whereas,  ifthu  precaution  is  ob- 
served, the  symmetry  and  usefulness  of  the  hand 
can,  in  a  great  measure,  be  preserved.  Sorrel]  re- 
ports two  successful  disarticulations  of  the  wrist 
joint. 

In  amputating  the  lore-arm  everj  efforl  should  be 
made  to  preserve  as  much  of  the  member  as  possible 
with  a  view  to  its  future  usefulness.  Great  care 
Bhould  be  taken  to  have  the  bones  of  equal  length 
and  exactly  parallel,  for  otherwise  they  will  protrude 
through    the    flaps,  producing  ulceration,  or,   it  may 

conical  stuinp.  From  the  1st  of  April  to  the 
end  of  the  Crimean  war.  Macleod  reports  54  opera" 
tions,  with, only  thm  death.-:  Dr.  Lente  reports  39 
operations  with  four  deaths,  Dr.  Haywood  reports  6 
with  one  death,  and  Sorrell  records  45,  with  only  (5 
deaths,  and  39  recoveries  -all  going  to  show  that  the 
rate  of  mortality  attending  it  is  very  low.  For  far- 
ther particulars,  consult  Table  "  D"  of  the  Appen- 
dix. 

All  other  things  being  equal,  it  would  be  better 
lo  amputate  just  below  the   -'il, M\v  joint     rather  than 

through  it  ;  but,  the  danger  to  the  pal  tent,  from  sub- 
sequent inflammation  which  is  likely  to  involve  the 
articulation,  should  always  be,  taken  into  the  account 
by  the  Surgeon.  Amputation  at  the  elbow-joint 
was  firsl  performed  by  Ambrose  Pare  but  subse- 
quently sank  into  disrepute.  It  has  since  been  re- 
vived by  Dupuytren  and  Velpeau,  and  may  be  per- 
formed with  propriety  when  the  operator  desires  to 
avoid  the  danger  from  inflammation  referred  to 
above,  or  to  preserve  a  more  useful  member  than  an 
U 


166  STATISTICS. 

Operation  above  that  point  would  allow.  The  opera- 
tor should  never  forget  that  the  articulation  proper 
is  below  the  tuberosities  of  the  humerus,  and  that  he 
may  be  readily  misled  by  appearaces  into  tranfixing 
too  high  and  thus  making  the  flaps  too  short  to  cover 
the  head  of  the  bone. 

Amputation  of  the  upper  arm  can  be  very  readily 
performed  and  is  attended  with  great  success- 

STATISTICS. 

Reported  bj  Macleod,   Operations  102,  Mortality  2-1.5  per  rent. 

"  "  Norris,  32,           "  6.3         " 

"  "  Lente,                "  58,          "  40 

"  •'  Sorrell,              "  L92,          "                        •' 

"  ll  Haywood,         "  -l,          "  00         " 

The  reader  is  referred  to  fable  "E,?  of  the  appen- 
dix. 

To  Barron  Larrey  belongs  the  credit  of  having  ele- 
vated ampution  at  the  shoulder  joint  to  its  proper 
rank  in  the  art  of  Surgery;  and  the  subsequent  ex- 
perience particularly  of  military  Surgeons  has  de- 
monstrated the  correctness  of  his  views  in  regard  to 
it. 

STATISTICS. 

Reported  Uv   Macleod,  ii".   of  operation  no.  of  deaths   1-';. 

"  "    Buel,                               "  39,  "        18. 

"  "    Lunte,                               "  in,  "        11. 

"  "    Gross,                             "  25,  "        12. 

A  s  thisjoperation  is  general !y  performed  in  connexion 
with  some  wound  of  the  body  of  greater  or  less  mag- 
nitude, whereby  its  result  is  materially  controlled, 
statistical  tables  cannot  afford  a  just  estimate  of  its 
intrinsic  value.  This  fact  should  be  borne  in  mind 
by  the  military  Surgeon  particularly,  as  the  question 
of  the  propriety  and  results  of  this  operation  must 
constantly  present  itself  in  field  servii 

The  value  of  primary  amputation  is  particularly 


TREPHINING  •  171 

same  plane  with  the  external,  a  smaller  instrumeir! 
should  be  introduced  to  cut  through  it,  in  order  to 
avoid  tearing  the  dura-mater  at  one  point  before 
another. 

7.  Should  the  sinuses  be  opened,  hemorrhage 
ran  be  arrested  by  plugging. 

8.  8hould  the  middh  meningeal  artery  be  divid. 
ed,  the  hemowhage  i^;  serious,  and  difficult  to  con- 
trol. Compress  it  with  a  bit  o\'  lint,  placed  inside 
the  cranium,  and  retained  by  a  thread,  or  with  a 
plate  of  lead  brut  so  as  to  embrace  both  surfaces 
of  the  bone;  or  by  plugging  it  with  sealing  wax. 
Larrey  touched  the  bleeding  orifice  with  a  steel 
probe  heated  to  whiteness:  while  Dorseyand 
others  recommended  the  application  of  a  liga- 
ture. 

Operation  <>n  /Ac  bones  of  the  GVam'wm. — This  may 
be  divided  into  live  different  parts,  viz  :  denuda- 
tion of  the  bone;  perforation  of  the  bone;  rembr- 
al  of  the  detached  piece  of  bone:  removal  of  the 
cause  of  compression  ;  dressing  and  after  treat- 
ment. 

Denudation  of  the  bone.  —  Directions. — The 
point  of  the  cranium  upon  which  the  operation  is 
to  be  performed,  having  been  shaved  of  its  hair, 
and  the  patient  placed  in  proper  position,  divide 
l he  s<.ft  parts  by  means  of  n  crucial  or  semilunar 
incision  ;  dissect  up  the  Haps,  revert  them,  and 
have  them  held  oul  of  the  way  by  an  assistant. 
and  control  the  hemorrhage  from  the  severed 
sels,  either  by  applications  of  cold  water,  twist 
them,  or  ligatur 

The  first  incision  should  reach  to  the  bone,  a 


172  TREPHINING. 

the  flaps, wrapped  in  fine  linen  to  prevent  injury 
to  them. 

Perforation    of    the    bone. This    is    to    be 

accomplished  either  with  the  Hand  Trephine,  or 
the  Trepan  instrument  of  Hildanus,  which  may 
be  made  to  revolve  by  a  brace,  or  like  a  drill  by 
means  ot  a  bow.  The  former  is  preferable,  as  the 
Surgeon  can  control  it  better. t  Directions. — In- 
troduce the  pyramid  or  central  bit  beyond  the  level 
oi'  the  crown  of  the  instrument,  firmly  secure  it 
by  means  of  the  screw  attached  to  the  side  for 
that  purpose,  and  enter  the  trephine  into  the  bone 
with  a  semicircular  motion  of  the  hand,  until  the 
teeth  of  the  saw  have  reached  the  external  table 
and  made  for  themselves  ;t  furrow  in  it.  Xow  re- 
tract the  pyramid,  lest  it  injure  the  dura-mater: 
continue  the  rotary  motion,  holding  the  instru- 
ment perpendicularly  to  the  bone,  withdrawing 
from  time  to  time,  to  clean  its  teeth  with  the  brush 
and  to  enable  the  Surgeon  to  sound  the  depth  of 
the  groove ; — and  penetrate  both  the  diploe  and 
the  internal  table.  When  the  instrument  has  pene- 
trated at  several  points,  introduce  an  elevator  into 


{Dr.  G.  A.  D.  Gait  of  tlie  Confederate  Army  has  devised  a  new 

Trephine,  with  the  object  ol  avoiding  injury  to  the  membranes  and 

Bubstance  of  the  brain.    The  instrument  consists  of  a  truncate* 

with   peripheral  teeth   arranged   in  a   spiral   direction. 

crown  teeth.     When  applied  tin-  peripheral    teeth  acl    as  a   cutting 

wedge  so  long  us  the  counteracting  pressure  acts  on  the  crown 

On  the  removal  of  the  pressure  by  the  division  of  tin.  Cranial 

its  tendency  is  to  act  on  thr  principle  ol  a  screw,  but.  owing  to  its 

conical  form  and  the  direction  of  its  peripheral  teeth,  theacti^n 

and  the  instrument  penetrates  no  farther.     Dr.  Gait  says  that  he  has 

operated  on  the  dead  subject  twenty  times,  and  has  never  succeeded 

in  wounding  the  membrane,  although  he  has  endeavored  tp  do   bo. 

Subsequent  practical  experience  has  demonstrated  the  great  utility  of 

the  instrument. 


I    fi  A  PTER   TV. 


EXCISION  OF  BONES  A.ND  JOINTS. 

The  instruments  required  in  this  connexion  are 
the  Saw—Hey's,  Chain  aud  Circular ;— cutting  for- 
ceps; perforator;  mallet;  chisel;  gouge:  rasp: 
clovator:   scalpel,  &<  , 

By  the  circular  saw  is  meant  the  trephine,  an 
instrument  potent  for  good  or  evil,  according  to 
tin-  necessities  of  the  oast-  and  the  skill  and  judg- 
ment ofthe  Surgeon. 

Trepliining. — The  circumstances  under  which 
this  operation  has  been  recommended,  are  the  lol- 
owing :  fracture  o\'  the  skull  with  depression  of 
yhe  bone:  fracture  of  tin  hone  with  penetrating 
wound  ofthe  dura  matter;  epilepsy,  depending 
upon  depression,  or  upon  the  existence  of  some 
point  of  irritation  of  the  skull  :  and  the  presence 
of  foreign  bodies  in  the  cerebral  substance,  includ- 
ing effused  blood  and  pus. 

Locality  of  the  operation.  -Avoid  the  sutures; 
those  parts  *'i'  the  skull  immediately  over  impor- 
tant arteries  and  vein.-:  those  regions  of  the  skull 
where  the  two  tables  are  situated  at  some  distance 
from  each  other;  the  thicker  portions  of  the  bone; 
and  th<'  part  immediately  under  the  temporal  mus- 
cle. 

The  occipital  protuberance,  meningeal  artery, 
ami  the  sinuses  are  particularly  to  be  avoided. 

Mode  of  Applying  the  [ostrument.  -In  simple 
fracture  apply   the  instrument  with  the  pyramid 


1 70  TREPHINING. 

resting  near  one  margin  of  the  fissure  so  the  sec- 
tion may  extend  on  botli  sides.  In  fractures  with 
depression,  see  that  the  crown  of  the  instrument 
does  not  rest  upon  the  loosened  hone,  for  tear  of 
causing  laceration  or  irritation  of  the  soft  parts 
heneath. 

When  a  foreign  body  is  wedged  in  a  wound  and 
the  fracture  is  but  limited,  the  crown  of  the  tre- 
phine should  embrace  the  whole  .solution  of  con- 
tinuity. 

In  the  ease  of  extravasated  fluids,  operate  imme- 
diately over  the  seat  of  effusion,  which  is  frequent- 
ly on  the  opposite  side  fronvthe  wound. 

Position  of  the  Patient. — Make  the  patient  as- 
sume a  recumbent  position,  with  his  head  resting 
upon  a  well  cushioned  hoard,  and  firmly  held  by 
an  assistant.  . 

General  Hides. — 1.  Do  not  operate  simply  for  the 
injuiy,  but  tor  the  consequences  produced  by  it. 

2.  Do  not  be  hasty  in  resorting  to  the  operation, 
but  wait  for  nature  and  time  to  do  their  work. 

3  If  the  operation  be  not  performed  before  the 
development  of  inflammatory  reaction,  wait  for  its 
subsidence. 

4.  Bear  in  mind  that  in  the  young  the  skull  is 
more  yielding  than  in  the  old,  and  more  readily 
depressed  without  fracture. 

5.  In  caries  and  necrosis  it  is  deemed  mostpru> 
dent  to  permit  the  diseased  portions  to  separate 
themselves  until  they  can  he  seized  with  the  forceps 
and  extracted. 

6.  When  it  becomes  necessary  to  trepan  the 
frontal  sinus,  the  internal  table  not   being   on   the 


TREPHINING.  159 

the  groove,  and  seperate  the   circular  piece   from 
the  internal  table. 

The  division  of  the  diploe  can  be  readily  recog- 
nized 1  > \  the  ease  with  which  the  instrument  pen- 
etrates its  substance  and  the  bloody  detritus  which 
escapes.  This  structure  is  deficient  in  children 
and  old  persons, — a  fact  which  should  be  remem- 
bered in  operating  upon  them. 

When  the  trephine  has  to  be  applied  so  as  to 
cover  a  small  fractured  portion  oi'  the  skull,  or 
Borne  foreign  body  lodged  in  the  bone,  the  perfo- 
rator can  be  used  to  start  the  crown;  and  a  piece 
of  wood,  cork  or  sole  leather  with  a  bole  in  it  of 
the  proper  size,  and  firmly  held  by  an  assistant, 
will  serve  to  retain  the  instrument  in  position  un- 
til the  teeth  have  made  a  sufficient  groove  in  the 
bone. 

Where  fractures  exists  with  depression,  and  the 
margin  of  one  bone  overlapsihe  other  ;  where  there 
is  depression  without  fracture. and  where  an  enlarge- 
ment of  the  angular  tissue  has  to  be  effected,  an 
opening  may  be  made  with  1  ley's  saw.  A  piece 
of  leather  with  aerevicecui  into  it.  must  he  placed 
on  the  skull,  within  which  the  straight  end  of  the 
saw  plays  until  if  sufficiently  introduces  itself. 

Removal  of  the  detached  piece  of  bone.— Fas- 
ten the  bone  screw  into  the  orifice  made  by  the 
central  pin.  and  by  a  few  lateral  motions  detach 
the  piece.  It  is  hitter  to  introduce  the  elevators 
on  the  opposite  side*  of  the  piece  so  as  to  sepa- 
rate and  lift  it  out.  Sometimes  it  is  brought  out 
with  the  trephine  itself.     If  prominent  points  of 


174  TREPHINING. 

bone  remain,  they  should  be  carefully  removed 
with  a  lenticular  knife  or  Ilcys'  saw. 

To  remove  the  cause  of  Compression — If  it 
be  desirable  to  raise  a  portion  of  the  bone, — as  for 
fracture  with  depression — ,  introduce  the  Common 
Elevator  between  the  cranium  and  dura  mater? 
without  dividing  the  membrane,  and  gradually 
elevate  the  depressed  portion  by  using  the  opposite 
margin  of  the  bone,  or  the  finger  as  a  fulcrum- 
Loose  portions  of  the  bone  arc  to  be  picked  away 
with  the  forceps  and  if  the  operation  has  been 
undertaken  for  the  removal  of  a,  ball  or  any  foreign 
substance,  it  may  be  seized  with  the  forceps  and 
drawn  out,  unless  too  much  effort  be  required  to 
bring  it  away. 

If  the  operation  be  earty  done  for  extravasition 
or  effusion,  the  fluid,  if  on  the  outer  side  of  the 
dura-mater,  will  come  away  of  itself.  Should  it 
prove  to  be  blood  however,  it  must  be  broken  up 
with  the  finger  and  then  removed.  If  the  fluid  be 
below  the  dura-mater,  this  membrane  will  be  found 
detached  from  the  bone,  and  of  a  brownish  hue 
with  a  bulging  at  some  particular  point  and  a  feel- 
ing of  fluctuation  below.  To  remove  this  fluid  the 
dura-mater  should  be  punctured,  by  pushing  a 
straight  sharp  pointed  bistoury  through  it. 

Dupuytren  plunged  his  knife  deep  into  the 
ceretral  substance  itself,  and  opened  an  abscess  more 
than  an  inch  from  the  surface.  His  example  has 
been  followed  by  other  eminent  Surgeons,  but  it 
is  too  bold  and  dangerous  a  measure  for  universal 
imitation. 


TREPHINING.  175 

The  Dressing  and  after  Treatment. — Ap]  »1  v 
eold  water  dressings,  instead  of  the  cerate  &c,  re- 
commended by  older  Surgeons.  Do  not  disturb 
the  wound  until  suppuration  ensues,  when  it  may 
be  washed  and  carefully  dressed  twice  daily. 

Remarks. — As  late  as  the  eighteenth  century 
Trephining  was  practised  in  almost  every  variety 
of  wounds  of  the  head,  both  as  a  curative  and  a 
preventive  measure — or  a  means  of  protection  be- 
fore dangerous  symptoms  were  developed.  The 
Trephine  was  used  on  all  occasions  and  for  every 
possible  injury,  realizing-,  even  as  far  as  the  most 
eminent  Surgeons  were  concerned,  the  lines  to 
Sidrophel, — 

"He  used  trephining  of  (he  skull. 
As  often  as  the  moon  was  full.1" 

This  shameful  misapplication  has  been  most 
energetically  and  successfully  opposed  by  Dcsault, 
Abernethy,  Langenbeck,  Thy  sick,  Cooper  and 
others  until  more  rational,  as  well  as  safer  views? 
are  entertained  in  regard  to  the  operation  by  the 
whole  Profession.  The  reaction  against  the  use  of 
the  instrument  upon  the  cranial  bones  has  gone  so 
far  that  sonic  have  rejected  it  alto-ether  as 
dangerous    and   unm  under   all   circum- 

stances; but  Sir  A.  Cooper,  and  Sir  15.  Hrodie  have 
very  clearly  demonstrated  the  impropriety  of  this 
conclusion  so  far  at  leas!  a-  some  <■;  see  of  com- 
pound fractures  with  depression  arc  concerned. 

In  military  Surgery,  the  trephine  is  far  less  used 
than  formerly, -and  flic  experience  of  Stromyer 
Maeleod,    iicuitt.    Guthrie,    Cole    and    Chisolm 


176  TKEPHINING. 

clearly  demonstrates  not  only  its  inutility  in  the 
treatment  of  cranial  wounds  generally,  but  the  posi- 
tive detriment  resulting  from  its  employment  even 
in  many  cases  of  fracture  with  depression  and 
compound  fracture,  for  which  it  has  heretofore  been 
primarily  recommended.  Stromyer,  who  was 
Surgeon  in  chief  in  the  Schliswig — Holstein  Army, 
and  "  one  of  the  highest  authorities  in  Gun-shot 
wounds  of  the  head,"  positively  and  peremptorily 
affirms,  "  that  in  military  Surgery,  trephining  is  never 
needed."  This  opinion  is  endorsed  by  Loeffler? 
and  in  a  great  measure  sustained  by  Chisolm,  and 
other  more  modern  military  Surgeons. 

It  is  now  well  known  that  a  depression  of  the 
ovier  table  does  not  necessarily  indicate  a  corres- 
ponding depression  of  the  inner  tablet,  ana  that 
both  tablets  may  be  so  depressed  as  materially  lo 
compress  the  brain  without  interfering  with  the 
functions  of  that  organ,  or  developing  an  unfavor- 
able symptom.  Trephining  is  also  known  to  be  a 
serious  operation — to  be  nothing  ''more or  less  than 
boring  a  hole  in  a  man's  skull" — and  as  calculated? 
even  under  favorable  circumstances,  to  produce 
irritation  and  inflammation  of  the  delicate  mem- 
brane it  exposes,  and  of  the  sensitive  cerebral  sub- 
stance beneath.  These  facts,  taken  in  con- 
nexion with  the  recorded  experience  of  the  great 
authorities  previously  referred  to,  should  teach  the 
military  Surgeon,  the  vast  importance  of  deliberat- 
ing well  before  resorting  to  this  operation,  and  of 
only  employing  it  when  all  other  means  have  tail- 
ed to  produce  those  results  upon  which  the  salva- 
tion of  his  patient's  life  depends.     lie  should  avoid 


TREPHINING.  177 

all  haste  in  its  employment,  waiting  for  nature. 
assisted  by  oilier  more  rational  and  less  violent 
remedies,  to  relieve  the  symptoms  of  cerebral 
compression,  and  to  restore  the  patient  to  his  nor- 
mal condition,  [f,  however,  his  expectations  in 
this  regard  are  disappointed, — if  sensibility  and 
motion  fail  to  return,  while  coma  and  stertor  in- 
crease, in  despite  of  the  most  energetic  antiphlo- 
measures,  showing  such  an  augmentation  of 
congestion  in  the  cerebral  substance  as  immediately 
jeopardizes  the  patient's  life,  then,  the  Surgeon  may 
resort  to  the  trephine  as  a  "  forlorn  hope"  wheth- 
er the  fracture  be  simple,  compound,  or  com- 
minuted, or  whatever  the  nature  and  limits  of  the 
injury.  11*'  should  neither  endanger  his  pa- 
tient's life  by  resorting  too  hurriedly  or  indis- 
creetly to  the  Instrument,  nor  permit  him  to 
die  for  the  want  of  it  through  an  unbecoming 
timidity,  or  a  slavish  subserviency  to  fashion  and 
authority. 

The  trephine  may  also  be  applied  successfully  to 
any  one  of  the  long  bones,  when  attacked  with 
caries  or  necrosis,  and  for  the  purpose  of  removing 
foreign  bodies  impacted  in  them,  such  as  balls, 
pieces  of  metal,  &c. 

The  operation  is  nearly  the  same  in  these  cases 
us  that  just  described,  only  differing  according  to 
the  depth,  density  and  form  of  the  the  bone. 

The  experiments  and  observations  of  modern 
military  Surgeons  are  decidedly  favorable  ton 
tion,  particularly  in  those  eases  uherethe  choice 
is  between  the  removal  of  a  joint  and  amputation 
above  it.  Primary  resections  have  been  found, 
equally  as  important  as  primary  amputations. 


178  RESECTIONS. 

Resections  in  General. — Resections  are  under- 
taken 

1.  For  the  removal  of  the  articulations  alone. 

2.  For  the  removal  of  the  shafts  of  bones. 

2.  For  the  exterpation  of  certain  bones  entire. 
The  circumstances  which  justify  resection  are  : 

1.  Caries  of  the  articular  extremeties  when  oth- 
er means  have  failed. 

2.  Osteo-sarcoma,  spiua-ventosa,  and  malignant 
affections  generally. 

3.  Compound  and  comminuted  fractures,  such 
particularly  as  are  caused  by  conical  balls,  imping, 
ing  either  upon  the  shaft  or  articular  surfaces  of 
bones.  Also  the  protrusion  of  fragments  through 
the  skin,  when  they  cannot  be  replaced,  or  are  de- 
nuded of  their  periosteum. 

4.  Compound  luxations,  when  insurmountable 
obstacles  present  themselves  to  reduction. 

5.  Necrosis  of  bone,  when  elimination  is  tardy. 

6.  Projection  of  the  end  of  a  bone  beyond  the 
stump  in  badly  performed  operations. 

7.  Exostosis,  or  when  some  foreign  body  has 
lodged  in  the  bone  and  cannot  be  removed. 

Resection  should  never  be  attempted  unless  the 
patient  has  manifestly  strength  enough  to  bear  a 
difficult  operation  and  a  tardy  convalescence,  and 
it  is  therefore,  eontraindicafed  when  there  are 
symptoms  present  of  any  one  of  the  cachexias;  of 
unusual  nervous  susceptibility,  or  of  marasmus.  It 
is  also  frequently  exceedingly  difficult,  in  chronic 
affectious  of  the  joints  to  distinguish  between 
vessels,  nerves,  &c. ;  and. hence  there  is  danger  of 
tetanus,  protracted  suppuration,  purulent  absorp- 
tion, and  erysipelas. 


resb  noNS.  179 

Rules  for  Resections  in  general. — Distinguish 
well  the  anatomical  relations  of  the  parts  before 
commencing  the  operation.  Know  where  nerves, 
and  vessels  are  to  he  found,  for  it  is  exceedingly 
difficult  to  distinguish  them  during  the  resection. 

2.  In  addition  to  the  ordinary  instruments,  have 
on  hand,  a  cutting  forceps,  a  gouge,  a  mallet? 
and  saws  of  different  sizes  and  shapes. 

3.  Open  a  free  way  to  the  hone,  but  expose  as 
little  as  possible  of  the  muscles  and  tendons. 

4.  The  nerves,  the  veins  and  the  arterial  trunks 
are  never  to  be  divided  ;  while  the  tendons,  as  a  gen- 
eral thing,  must  he  preserved. 

5.  Before  employing  the  saw,  ascertain  to  what 
extentthe  bone  ffi  diseased,  and  see  that  the  soft 
parts  are  well  out  of  the  way  of  injury. 

6.  Remove  completely  every  part  touched  by 
the  disease  orieached  by  the  injury. 

7.  Cut  oil  the  bones  connected  with  the  articula- 
tions at  the  same  distance  from  the  joint. 

8.  Preserve  as  much  of  the  periosteum  and  take 
away  as  huge  a  portion  of  synovial  membrane  aa 
practicable. 

!'.    When  a  lower  limb  has  been  operated   upon 
bring  the  bones  together,  and  extend  it;  but  when 
an  upper,  put  it  in  a  state  of  semiflexion,  and  leave 
the  bones  a  little  apart  so  as  to  secure,  if  possible 
an  artificial  joint. 

1<>.  Make  the  i  on  the  side  opposite  to 

the  main  arteri< 

1  1.  Make  the  existing  wound  lie,  if  possible,  in 
the  line  of  one  of  the  incisions,  w  hi  eh  should  be  SO 
arrange. I  a    to  permit  the  free  drainage  of  pus. 


180  PARTICULAR    RE3BCriOJT3.     . 

Particular  Resections. — Resection  of  the  bones 
of  the  upper  limb. 

Resection  of  the  Metacarpo-phalangeal  articula- 
iion. — Either  the  head  ot  the  metacarpal  bone 
or  the  end  of  the  phalanx  may  be  removed.  Di- 
rections; commence  hall' an  inch  from  the  point  at 
which  the  saw  is  to  be  applied,  and  make  a  Hap 
with  its  base  towards  the  linger;  dissect  up  this 
flap;  turn  aside  the  extensor  tendon  and  separate 
the  muscles  from  the  bono;  open  the  joint  care- 
fully, so  as  not  to  divide  the  flexor  tendons;  dis- 
articulate and  isolate  the  diseased  portion;  and  then 
'slip  a  small  peice  of  wood  or  a  spatula  under  the 
bone,  and  saw  it  oft*. 

Extraction  of  the  First  Metacarpal  Bone. — Direc- 
tions.— Make  an  incision  along  its  radial  border, 
extending  half  an  inch  beyond  each  articulation  ; 
cautiously  detach  the  skin  and  tendon  from  its 
dorsal  surface  and  the  muscles  from  its  palmar  face; 
have  the  edges  held  well  apart  and  cany  the  knife 
through  the  upper  articulation  ;  then  luxate  the 
bone  outwards  and  pass  the  knife  completely 
along  its  inner  surface  ;  and  finally  carry  the  knife 
through  its  lower  articulation.  The  radial  artery 
may  be  avoided,  but  if  cut  it  can  be  readily  lega- 
ted. Close  the  wound,  and  keep  the  parts  in  their 
normal  position. 

The  other  bones  of  the  metacarpus  may  be  re- 
moved by  following  the  same  general  plan. 

Resection  of  the  Wrist  Joint. — Directions. — Make 
two  longitudinal  incisions,  terminating  on  a  level 
with  the  articulation,  one  along  the  outer  side  of 
the  radius,  and  the  other  along  the  inneraide  of 


KESECTIONS  OF  WRIST  JOINT  181 

the  ulna,  near  their  anterior  edges  ;  unite  them  by 
a  transverse  incision  across  the  back  of  the  wrist; 
dissect  up  this  quadrilateral  flap,  avoiding  the 
tendons  which  glide  in  the  grooves  of  the  bone  ; 
draw  the  tendons  aside,  as  much  as  possible,  and 
detach  the  soft  parts  ;  and  then  pass  a  spatula  un- 
der the  bones  and  saw  both  ulna  and  radius  at 
once.  Bring  the  parts  together  and  treat  on  gen- 
eral principles.  The  tendons  which  control  the 
motins  of  the  joint  may  be  divided  in  an  emergen- 
cy and  the  knife  passed  more  directly  into  the 
joint,  as  it  is  not  expected  to  preserve  the  move, 
ments  of  the  articulation  after  the  operation. 

Remarks. — In  consequence  of  the  close  connex- 
ion of  this  articulation  with  the  flexor  and  extensor 
tendons,  consolidation  of  these  and  their  sheaths  is 
likely  to  occur,  together  with  the  consequent  loss 
of  motion  in  the  hand.  Many-  cases,  however, 
will  be  found  in  which,  even  with  a  stiff  wrist,  there 
may  be  some  motion  of  the  fingers;  and  with  all 
the  disadvantages  attending  this  operation,  it  is 
far  better  to  have  a  hand.  Whatever  may  be  its 
condition,  as  regards  mobility,  than  no  hand  at  alb 
The  lower  extremities  of  the  radius  and  ulna 
maybe  excised;  while  the -carpus  remains  intact 
if  these  bo, ies  alone  are  involved  in  the  the  dis- 
ease or  injury,  by  simply  following  the  first  steps 
of  the  operation,  as  above  pointed  out. 

irpation  of  the  Radius. — Directions. — Semi- 
flex  the  arm  ;  make  a  longitudinal  incision  on  the 
external  anterior  border  of  the  radius,  so  as  to  lay 
it  bare;  dissect  back  the  integuments;  push  the 
soft  parts  aside  ;  pass  a  director  or  scalpel  umler 
8 


182  RESECTIONS  OF  ULNA. 

the  bone  and  saw  through  it ;  clear  the  fragments 
from  the  soft  parts;  and  then  separate  them 
from  their  articulations,  avoiding  the  nerves  and 
arteries. 

Resection  of  the  Body  of  the  Ulna. — Directions. — 
Make  a  transverse  incision  down  to  the  bone, 
four  inches  and  a  half  below  the  olecranon,  and 
extending  a  little  more  than  half  the  diameter  of 
the  arm;  make  another  longitudinal  incision,  inter- 
secting the  lower  part  of  the  former,  and  along 
the  most  superficial  portion  of  the  bone  down  to 
the  wrist  joint ;  commence  at  the  first  incision  and 
dissect  the  soft  parts  around  the  bone  for  three 
inches;  insert  a  spatula  and  saw  through  the  bone 
transversely;  continue  the  dissection  to.  the  wrist 
joint ;  and  then  disarticulate  and  remove  the  bone. 
Avoid  wounding  the  ulna  nerve,  and  tie  the  ulna 
and  interosseous- arteries  if  divided. 

Theinferior  extremity  of  the  ulna  maybe  resec- 
ted by  making  a  longitudinal  incision  along  the 
border  of  the  ulna ;  then  making  another  longitu- 
dinal incision,  aross  the  back  of  the  joint;  dissect- 
ing up  the  flap  and  turning  it  back ;  drawing- 
aside  the  tendons;  and  disarticulating. 

Remarks — Several  cases  are  recorded  of  success- 
ful removal  of  the  ulna  and  radius,  and  the  results 
attending  the  operation  are  sueh  as  to  warrant  the 
Surgeon  in  resorting  to  it  under  some  circum- 
stances. It  may  be  more  advantageously  attempt 
ted  for  disease  than  for  injury,  as  the  soft  parts  are 
less  likely  to  be  involved  in  the.  first  instance 
than  in  the  last.  Resection  of  the  radius  is  more 
likely  to  interfere  with  the  mobility  and  symmetry 


RESECTIONS  OF  ELBOW-JOINT.  183 

of  the  arm,  than  the  removal  of  the  ulna,  for  ob- 
vious reasons. 

Ki  section  of  the  elbow  joint. — Surgeons  are 
much  divided  as  to  the  best  operation  for  the  ex- 
cision of  this  joint,  some  advocating  the  H,  and 
others  the  H  shaped  incision;  while  still  another 
class  prefer  Bucks  modification  of  the  latter,  which 
consists  of  two  longitudinal  incisions,  the  horizon- 
tal cut  being  omitted  and  the  sides  directed  so  as. 
to  expose  the  bone  without  dividing  the  attach- 
ment of  the  tendon  of  the  triceps.  Ordinarily  the 
following  plan  will  be  found  the  most  available. 
•  lions:  Place  the  Patient  on  his  face,  near  a 
well  lighted  window,  upon  a  table  four  feet  high, 
so  that  his  arm  is  supported  and  presents  to  the 
Surgeon  the  posterior  and  internal  face  of  the  arti- 
culation :  then,  make  an  II  shaped  incision,  taking 
in  the  breadth  of  the  articulation,  exposing  the 
heads  of  the  bones,  and  dividing  the  skin  and 
tendon  of  the  triceps;  dissect  back  these  flaps 
carefully,  taking  care  to  remove  the  ulna  nerve 
from  its  bed  on  the  inner  side  of  the  arm,  behind 
the  epitrochlea;  divide  the  posterior  ligaments  and 
expose  the  joint,  separate  the  soft  parts  carefully, 
avoiding  the  nerves  and  arteries;  pass  the  handle 
of  a  scalpel  under  the  humerus ;  saw  off  and  detac 
as  largo  a  portion  of  the  humerus  as  may  be  ne- 
,  ry;  and  finally,  attack  the  bones  of  the  fore, 
arm  and  such  portions  of  these  as  may  be 

. — remembering,  that   if  either  one  of 
them  is  not  implicated  in  the  disease  or  injury,  to 
leave  it  unmolested. 
Then  close  the  lips  of  the  wound   by  means  of 


184  RESECTIONS  OF  ELBOW-JOINT. 

sutures;  leave  the  bones  slightly  separated;  keep 
the  limb  upon  pillows  and  rely  exclusively  on 
the  cold  water  dressing.  Remember,  however,  to 
prevent  anchylosis  by  passive  motion  of  the  joint 
when  the  soft  parts  have  cicatrized.  It  is  a  matter 
of  great  consequence  not  to  remove  more  of  the 
bones  than  is  absolutely  necessary. 

The  shaft  of  the  humerus  should  not  be  en- 
croached upon,  if  it  is  possible  to  avoid  doing  so, 
or  the  excision  of  the  radius  and  ulna  carried  be- 
low the  insertion  of  the  brachialis  anticus  and 
triceps.  The  position  of  the  parts,  and  the  rela- 
tions of  the  bones  to  each  other  should  be  scrupu- 
lously attended  to,  bagging  of  matter  prevented 
and  exuberant  granulations  repressed. 

Remarks. — This  is  comparatively  a  modern  pro- 
cedure, having  been  suggested  by  Park  of  England 
in  1781,  and  performed  by  Moreau  in  1782.  It  is 
to  Roux,  Crampton  and  Syme,  however,  that  the 
profession  is  indebted  for  the  revival  and  vindica- 
tion of  this  operation — thus  securing  moveable 
joints  and  comparatively  useful  members  to  many 
who  otherwise  would  have  been  deprived  of  their 
arms.  As  a  proof  of  the  utility  of  this  operation, 
it  is  only  necessary  to  refer  to  a  few  facts,  which 
have  been  collected  in  regard  to  it.  During  the 
Schleswing-IIolstein  campaign,  Langenbeck  and 
Stromyer,  report  that  of  fifty  four  amputations  of 
the  arm,  nineteen  died,  whereas  of  forty  resections? 
performed  under  identical  circumstances,  and  with 
similar  appliances  for  operating, dressing  and  trans- 
porting, only  six  died.  Macleod  records  20  opera- 
tions for  excision  of  this  joint,  and  seven  deaths, — 


RESECTIONS  OF  ELBOW-JOINT.  185 

four  following  secondary  resections,  and  not  being 

connected  with  the  operation.  To  this  might  be 
added  the  testimony  of  hundreds  in  civil  practice, 
both  in  America  and  Europe:  whilst  if  the  ex- 
perience of  Confederate  Surgeons  were  properly 
collected,  the  value  of  this  operation  would  he 
rendered  still  more  apparent  to  the  medical  world. 

The  importance  of  Primary  resections  is  particu- 
larly conspicuous.  Thus,  of  eleven  cases  excised 
within  twenty  four  hours  before  reaction  had  set  in, 
but  one  died  ;  oitioenty  cases  between  the  second  and 
fourth  day,  or  during  the  stage  of  irritation  and  ex- 
citement, four  died;  and  of  nine  cases  operated 
upon  between  the  eighth  and  thirty  seventh  day, 
only  one  died. 

The  necessity  for  this  operation  is  not  so  great 
when  the  joint  has  been  opened  by  a  sabre  cut,  as 
when  a  ball  has  passed  through  it,  grinding  up  the 
bones,  annihilating  the  ligaments,  and  complete- 
ly destroying  the  articulation.  Sorrell  reports  six 
operations  and  four  deaths.  AVounds  of  this  joint 
may  be  readily  recognized  by  the  following  cir- 
cumstances :  the  facility  with  which  the  interior 
of  the  joint  can  be  reached  by  the  probe  or  fin- 
ger; the  general  direction  of  the  wound  ;  prefer 
natural  mobility  or  entire  loss  of  motion  ;  and  the 
escape  of  synovia — circumstances  which  should 
always  be  taken  into  the  account  because  of 
the  imperative  necessity  for  promptness  in  the 
performance  of  the  operation  if  the  wound  has 
really  involved  the  articulation. 

"Resection  of  \  l$er  Joint. — The.  operations 
of  White,  Lisfranc,  and  Syme  have   all    their   ad" 


186  RESECTIONS  OF   SHOULDER  JOINT. 

vocates,  but  the  following  plan,   is  perhaps  the 
Lest  as  a  general  rule. 

Directions. — Compress  the  Subclavian  Artery 
above  the  clavicle  ;  make  a  V  shaped  Flap  of  the 
deltoid  muscle  about  three  inches  long,  beginning 
at  the  acromion  process  and  terminating  on  the 
upper  and  outer  portion  of  the  arm;  dissect  this 
up  and  expose  the  capsular  ligament  of  the  joint; 
ligate  the  circumflex  arteries  which  are  divided 
in  the  first  incision;  carry  the  arm  over  the  chest; 
divide  the  capsular  ligament  and  turn  the  head 
of  the  humerus  out  of  the  glenoid  cavity;  remove 
the  long  head  of  the  biceps  from  its  groove;  place 
a  spatula  behind  the  bone ;  and  then  remove  with 
the  injured  portion  of  the  humerus. 

This  being  done,  return  the  flap  to  its  proper 
position;  place  the  patient  in  bed ;  support  the  arm 
upon  soft  pillows;  and  apply  cold  water  dressings. 
The  most  tedious,  and  perhaps  embarrassing  por- 
tion of  the  operation,  is  the  removal  of  the  tendon 
of  the  biceps  from  its  bed.  Rather  than  prolong  the 
sufferings  and  dangers  of  the  patient  unnecessarily, 
it  is  better  to  sever  this  tendon,  and  to  conclude  the 
operation,  as  experience  demonstrates,  that  no  seri- 
ous inconvenience  results  from  such  a  course.  The 
deltoid  is  usually  paralyzed  after  this  resection 
even  when  "White's  operation  is  performed  but  the 
other  muscles  surrounding  the  joint  form  new  re- 
lations, and  a  very  useful  limb  is  secured  to  the 
patient — though  considerably  shortened,  and  some- 
what deformed.  It  is  best  to  place  the  limb  upon 
a  pillow  or  a  long,  broad  splint,  without  applying 
bandages,  and  to  keep  the  patient  perfectly  quiet 


RESECTION  OF  SHOULDER  JOINT.  187 

until  the  inflammatory  stage  lias  past,  and  suppura- 
tion has  been  established, — when,  with  his  arm 
carefully  placed  in  a  sling,  he  may  bo  permitted  to 
walkabout.  If  suppuration  be  excessive,  sustain 
his  strength  by  the  free  use  of  stimulants  and  a 
liberal  diet. 

Jl<  marks. — This  operation  is  usually  successful, 
more  so  perhaps  than  most  of  the   Amputations, 
and,  as  it  can  be  readily  performed,  it  should  com 
mend  itself  particularly  to  the  attention  of  military 
Surgeons. 

STATISTICS. 


e  ported  by  Larrey, 

Operations 

10 

deaths 

4* 

BaudeDS, 

(i 

14 

<< 

1 

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Rules  to  be  observed  in  Resection  of  the  shoul- 
der Joint : 

1.  Perform  primary  rather  than  secondary  opera- 
tions. It  must  not  be  forgotten,  however,  that 
secondary  resections  of  this  joint  though  inferi- 
or to  primary,  are,  according  to  Stomeyer  and 
Esmarch,  more  successful  than  those  of  other 
joints. 

2.  It"  upon  a  proper  examination  only  a  portion 
of  the  head  of  the  humerus  is  found  injured,  remove 
that  and  leave  the  remainder  intact.     This  will  at 

facilitate  the  healing  of  the  wound,  if  it  does 
not  secure  so  useful  a  member. 

3.  The  whole  head  and  a  considerable  portion 


me  wore  directly  attributable  to  the  operation.    Thus 
2  died  of  Scorbutus,  1  of  Hospital  Fever,  and  1  of  Test  aftei 


IS 

after 
recovery. 


188  RESECTIONS  OF   SHOULDER  JOINT. 

of  the  shaft  may  be  removed,  with  advantage,  if 
implicated.  Thus,  though  Guthrie  believed  that 
the  insertion  of  the  deltoid  was  the  lowest  point  at 
which  the  bone  should  be  divided,  Esmarch  has 
shown  that  at  least  four  and  a  half  inches  can 
be  removed  and  yet  a  most  useful  arm  remain. 

4.  The  U  incision  facilitates  the  performance  of 
the  operation,  but  the  straight  incision  of  White 
secures  a  greater  degree  of  motion,  as  it  does  less 
injury  to  the  deltoid  muscle.  It  is  important, 
however,  in  gun-shot  wounds  to  include  the  two 
openings  in  the  incision. 

6.  Arrange  the  line  of  incision  so  as  to  give 
free  exit  to  the  pus  which  is  produced  in  large 
quantities,  so  as  to  avoid  sinuses  and  abscesses  in 
the  neigborhood  of  the  joint. 

6.  In  field  practice  it  is  not  necessary  to  make 
the  incision  so  extensive,  as  under  other  circum- 
stances. The  muscles  and  tendons  being  thus 
preserved  afford  a  better  chance  of  restoring  the 
action  of  the  limb,  while  the  healing  process  goes 
on  with  more  rapidity  and  success. 

7.  If  the  head  of  the  humerus  be  entirely  detach- 
ed, and  thereby  increase  the  difficulty  of  disartic- 
ulation, it  may  be  seized  with  the  fingers,  or  a 
pair  of  strong  bullet  forceps,  and  the  manipulation 
facilitated. 

8.  It  is  well  to  compress  the  artery  above  the 
clavicle,  or  to  have  arrangements  made  to  do  so 
with  celerity  and  success  in  the  event  of  too  great 
a  flow  of  blood. 

9.  Avoid  wounding  the  nerves,  vessels  and  the 
glenoid  cavity  during  the  operation. 


RESECTIONS  OF  SHOULDER  JOINT.  189 

10.  Never  operate  on  the  field  proper,  unless 
there  are  facilities  on  hand  for  supporting  the  limb 
and  for  transporting  the  patient  to  someneighbor- 
i  ng  hospital. 

11.  Support  the  patient's  system,  both  as  a 
means  of  relieving  or  preventing  shock,  and  of 
securing  that  "  plasticity"  of  constitution  upon 
whieh  a  speedy  convalescence  and  a  proper  union 
so  much  depend. 

Stomeyer  prefers  a  semicircular  incision  over 
the  posterior  surface  of  the  articulation  ;  Langeu- 
beck  favors  one  straight  incision  on  the  anterior 
aspect  of  the  joint;  Franke  and  Schleswic  add  to 
this  a  transverse  cut ;  Baudens  makes  a  straight 
incision  on  the  inside  of  the  arm  ;  Macleod  in- 
clines to  the  perpendicular  cut  of  White  immedi- 
ately through  the  deltoid  ;  while  Chisolm  advo- 
cates the  U  shaped  incision  described  in  the  pre- 
ceding pages  of  the  work. 

The  daugers  of  cutting  across  the  fibres  ot  the 
deltoid,  are  for  the  most  part  imaginary,  in  as 
much  as,  according  to  the  practical  experience  of 
all  who  have  witnessed  and  practised  this  opera- 
tion, the  fibres  of  that  muscle  speedily  form  unions 
which  give  them  control  over  the  arm  to  a  very 
considerable  extent. 

Velpeau  seems  to  have  been  particularly  unfor- 
tunate with  this  operation.  He  reports  thirteen 
deaths  from  it,  and  says  that  many  more  have 
occurred  within  his  knowledge.  The  weight  of 
testimony  is,  however,  decidedly  in  favor  of  it;  and 

when  the  experience  of  Confederate  Surgeons  is 
8b 


190         RESECTIONS  OF  CLAVICLE, 

accurately  recorded  the  weight  of  testimony  in  its 
favor  will  be  overwhelming. 

Reseetions  of  the  Clavicle  and  Scapula. — Circum- 
stances occassionally  demand  these  operations, 
though  they  are  of  rare  occurrance.  Watt  has  re- 
sected the  entire  clavicle  by  making  three  incisions, 
circumscribing  a  quadrilateral  flap,  and  disarticu- 
lating the  bone  at  either  extremity.  The  Scapula 
has  also  been  removed  in  its  totality,  but  it  is  too 
difficult  and  dangerous  an  operation  to  be  repeated 
save  in  the  most  extraordinary  cases. 

There  are  no  general  rules  for  these  operations, 
but  each  Surgeon,  relying  upon  his  knowledge  of 
anatomy  and  his  acquaintance  with  surgical 
principles  generally,  must  proceed  as  his  judgment 
dictates. 

Kesection  of  the  Bones  of  the  Lower  Ex- 
tremity.— Resections  of  these  bones  are  not  so  suc- 
cessful as  of  the  upper  extremity. 

Resection  of  the  Anterior  End  of  the  first  Meta- 
tarsal bone. — Directions  :  Cut  a  flap  on  the  inside 
with  its  base  posterior ;  denude  the  bone  to  the 
joint  at  which  it  is  to  be  cut;  saw  it  perpendicidar- 
ly  to  its  axis  ;  detach  it  from  the  soft  parts  ;  and 
then  separate  it  from  the  phalanx.  This  bone  has 
been  completely  exterpated  by  Malgaigne. 

Excision  and  Resection  of  the  Bones  of  the  Tarsus. — 
No  precise  rules  can  be  established,  but  the  opera- 
tion is  easy  and  the  result  satisfactory.  The  space 
left  by  the  removal  of  the  bone  is  filled  up  by 
matter  which  subsequently  ossifies,  and  thus,  in 
a  measure,  prevents  deformity  and  enables  the  pa- 


feient  eventually,  to  walk  well.  Caries,  or  necrosis 
of  the  oscalcis  is  a  serious  circumstance,  since, 
when  its  inferior  surface  is  excised,  the  equilibrium 
of  the  body  is  destroyed,  and  the  weight  thrown 
forward  on  the  point  of  the  foot;  while  if  the  tendo, 
Achillis  is  cut,  great  inconvenience  results.  But 
even  with  these  disadvantages,  resection  is  better 
than  amputation,  as  the  limb  is  saved,  and  the 
patient  can  walk,  however,  imperfectly. 

The  astragalus  may  also  be  ^xtirpated,  by  lux- 
ating the  bone  through  the  integuments,  and  di- 
viding its  attachments ;  but  the  state  of  the  parts 
must  furnish  the  proper  guide  to  the  Surgeon. 
After  this  operation  the  foot  is  fixed  to  the  heg 
and  the  resulting  lameness  great. 

m  of  the  Ankle  Joint. — Directions. — Make 
an  incision  three  inches  long,  from  the  inferior  and 
posterior  portion  of  the  outer  malleolus  ;  from  the 
lower  end  of  this  cut,  make  another  transversely 
forwards  and  only  dividing  the  skin ;  dissect 
back  the  flap  and  disengage  the  fibula;  and  sep- 
erate  the  external  malleolus  from  the  other  bones 
with  the  chissel  and  mallet, — not  employing  the 
saw,  because  as  there  is  no  interoseous  space, 
nothing  can  be  introduced  behind  the  bones  so  as 
to  protect  the  soft  parts.  Dress  in  the  usual  way. 
\arks. — Resection  of  this  joint  has  not  suc- 
ceeded so  well  as  that  of  the  others  mentioned 
above,  or  even  of  the  knee.  It  is  recommended 
by  the  teachings  of  conservative  Surgery;  but  the 
experience  of  the  profession  is  against  its  practi- 
cal utility,  and  amputation  is  now  regarded  as  de- 
cidedly preferable. 


192  RESECTIONS  OF  FIBULA 

Removal  of  the  Fibula. — This  bone  may  be  re- 
moved either  in  its  entirety,  or  partially. 

Directions. — Make  an  incision  three  inches  long 
on  the  inferior  portion  of  the  bone,  or  for  its 
whole  length ;  detach  the  soft  parts  as  high  up  as 
the  operation  is  to  be  performed ;  divide  the  bone  ; 
and,  then  detach  it  from  its  articulation  with  the 
tibia, — taking  car#to  cut  as  close  as  possible  to  the 
bone  so  as  to  avoid  the  anterior  tibial  artery. 
The  same  general  plan  may  be  followed  for  the 
removal  of  the  upper  portion  of  the  bone,  or  for 
the  whole  of  it.  Portions  of  the  tibia  may  be  re- 
moved on  the  same  general  plan. 

Resection  of  the  Knee  Joint. — This  operation  was 
first  performed  by  Park  in  1781,  and  has  been  va- 
riously modified  by  Moreau,  Begin,  and  Syme. 

Among  the  various  processes  proposed  in  this 
connexion,  the  following  offers  the  most  decided 
advantages. 

Directions. — Bind  the  leg  at  a  right  angle  to  the 
thigh  ;  make  a  transverse  incision  slightly  curved 
and  with  its  convexity  downwards,  under  the  pa- 
tella cutting  into  the  articulation  ;  make  then, 
two  longitudinal  incisions  upon  either  side  of  the 
limb  and  perpendicular  to  the  first ;  dissect  up 
this  flap,  including  in  it  the  patella  ;  destroy  first 
the  lateral  and  the  posterior  ligaments ;  carefully 
detach  the  soft  parts  from  the  femur  then  pass  a 
a  wooden  splint  or  piece  of  thick  leather  under 
it ;  and  remove  the  injured  or  diseased  portion 
with  the  saw.  If  the  tibia  be  injured  or  affected, 
extend  the  perpendicular  flap ;  separate  the  soft 


RETECTIONS  (  F   KNEE  JOINT.  103 

parts  from  the  tibia,  and  remove  a  portion  of  it 
with  the  saw. 

The  patella  may  bo  removed  or  not  according 
to  the  judgment  of  the  Surgeon.  Syme  advises  its 
removal,  but  on  the  other  hand,  Pancoast  declares 
that  it  should  unquestionably  be  left,  "as it  will 
serve  to  furnish  a  broader  basis  for  the  subsequent 
union  of  the  bones." 

If  any  small  arteries  are  cut  they  should  be  im- 
mediately ligated  ; — the  parts  brought  carefully 
together;  and  a  hollowed  splint  then  applied 
to  the  posterior  surface  of  the  limb,  extending 
from  the  buttocks  to  the  heel, — while  cold  water 
dressings  are  applied  to  the  wound.  It  is  useless 
to  expect  a  speedy  convalescence  ;  and  it  is  not 
improbable,  that  profuse  suppuration,  numerous 
abscesses,  and  exfoliation  of  bone  may  present 
themselves  at  some  period  in  the  history  of  the 
case  ;  but  if  the  Surgeon  will  watch  the  patient 
closely  and  see  that  his  system  is  kept  up  to  its 
normal  tone,  &c.,  a  favorable  result  may  eventual- 
ly be  predicted  and  obtained  in  some  cases. 

Ba  marks. — This  operation  is  a  modern  one,  dat- 
ing back  only  to  the  year  1781,  when  it  was  first 
performed  by  Park,  and  has  not  yet  received  the 
endorsement  of  the  profession.  A  few  remarks  as 
to  the  relative  value  of  resections  of  the  knee  joint 
will  not  be  out  of  place  in  this  connexion.  It  is 
well  known  that,  when  this  joint  is  opened,  what- 
ever the  extent  of  the  injury  or  the  nature  of  the 
missile  inflicting  it,  violent  inflammation  of  the  sy- 
novial membrane  lining  the  articular  cavity  and 
of  the  tissues   surrounding  its  exterior,  speedily 


194  RESECTIONS  OF  KNEE  JOINT. 

follows,  accompanied  by  great  pain,  excessive 
heat,  considerable  tumefaction,  and  violent  fever. 
Should  this  primary  stage  be  survived,  then,  ery- 
sipelas, pyeernia,  and  irritative  fever  develop  them- 
selves, adding  their  baneful  influence  to  the  mul- 
titudinous dangers  which  encompass  the  sufferer. 
These  facts  being  remembered,  it  becomes  the  du- 
ty of  the  medical  man,  to  attempt  some  interfer- 
ence by  which  immediate  relief  may  be  afforded 
to  his  patient,  and  amputation  and  resection  become 
the  alternatives  which  present  themselves  to  his 
mind.  It  is  important,  therefore,  to  have  an  ac- 
curate knowlodge  ot  the  relative  value  of  these 
two  operations,  as  upon  the  decision  of  the  Sur- 
geon, human  life — the  existence  of  a  hero  and  a 
martyr — may  depend.  Eelief  must  come  quickly 
if  it  come  at  all.  There  is  no  time  for  delay  or 
investigation  when  the  mutilated  victim  appeals 
for  succor.  The  comparative  difficulties,  dangers 
and  results  of  the  two  operations  should  be  fully 
comprehended  and  properly  appreciated  in  ad- 
vance, so  that  an  intelligent  response  may  be 
made  to  the  demands  of  science  and  humanity, 
without  hesitation  or  delay. 

The  advantages  claimed  for  Resection  may  be 
thus  summed  up : 

1.  In  the  event  of  a  successful  issue,  the  life  and 
limb  of  the  patient  are  both  saved, — the  latter  an. 
chylosed  and  deformed  it  is  true,  but  still  not  en- 
tirely useless. 

2.  But  a  small  quantity  of  blood  is  lost  during 
the  operation,  and  there  is  no  danger  of  seconda- 


OF  KNEE  JOINT.  195 

!'v  hemorrhage — an  accident  which  seriously  com- 
plicates and  materially  endangers  all  amputations. 

3.  There  is  Less  of  the  substance  of  the  limb  de- 
stroyed, and  the  shock  to  the  system  is  not  so  great 
as  in  amputation. 

4.  In  civil  practice  the  results  of  resection  have 
been  comparatively  favorable. 

The  objections  urged  against  the  excision  of  the 
knee  joint,  may  be  thus  stated: 

1.  Even  in  the  event  of  success,  the  limb  is  so 
completey  anchylosed  and  deformed  as  to  be  less 
useful  than  an  artificial  limb  of  proper  construc- 
tion. 

2.  Though  the  danger  from  secondary  hemor- 
rhage is  less,  erysipelas,  purulent  infection,  ex- 
cessive  and  prolonged  suppuration,  irritative  fever, 
and  marasmus,  with  their  attendant  evils,  are  more 
likely  to  occur,  than  after  amputations. 

3.  The  convalescence  is  always  tedious,  involv- 
ing a  long  confinement  in  the  recumbent  position, 
and  producing  the  most  serious  inconvenience  to 
the  patient  because  of  the  absolute  repose  deman- 
ded by  the  necessities  of  the  case. 

4.  Without  the  most  perfect  repose — the  absence 
of  all  motion,  and  the  most  careful  after  treatment 

danger  of  destructive  inflammation  aud  of 
great  deformity.  These  constitute  the  necessary 
condition  in  the  proper  treatment  of  the  case — the 
sin$  q  ►fits  management.     This  fact  renders 

■;ion  of  the  knee  joint  in  field  surgery   almost 
impracticable  in  view  of  the  means  of  traneporta- 


196  RESECTIONS  OF  KNEE  JOINT. 

tion,  appliances,  &c,  at  the  command   of  medical 
officers.  J 

5.  The  experience  of  military  Surgeons  does 
not  prove  this  to  be  so  reliable  an  operation  as 
amputation  in  the  lower  third  of  the  thigh.  Mac 
leod  reports  only  one  case,  and  that  an  unsuccess- 
iul  one  in  the  Crimean  campaign.  Moreau  re- 
ports three  cases  in  his  experience,  all  of  which 
proved  fatal.  The  former  writer  uses  in  this  con. 
nexion  the  following  significant  language,  "  Ad- 
miring, as  I  do,  the  brave  attempts  which  have 
been  made  in  civil  practice  to  save  limbs  by  ex- 
cising the  knee,  I  regret  that  it  should  not  be  ex- 
tended to  milita  practice ;  but  except  in  rare  cases 
I  fear  that  it  cannot  be  accomplished,  from  the  care- 
ful after  treatment,  and  the  long  period  of  conval- 
escence necessary  to  effect  a  cure." 

The  Surgical  society  of  Paris  has  decided  posi- 
tively and  unanimously  against  this  operation,  in 
connexion  with  a  case  of  resection  submitted  by 
Maisonneuve.  So,  likewise,  Park  declares  that 
this  operation  indicates  "  more  courage  than  judg- 
ment on  the  part  of  the  operator;"  while  Vidal, 
"  in  view  of  the  dangers,  delays,  and  bad  results  " 
attending  it,  enters  his  formal  protest  against  its 
employment. 


\  Erichsen  warmly  advocates  this  operation  in  civil  practice,  and 
gives  twenty-four  cases,  of  which  seventeen  were  successful  and  eight. 
died.  Ferguson  speaks  of  more  than  one  hundred  cases,  with  a  mor- 
tality greatly  less  than  that  for  the  thigh.  Syme  favors  the  operation 
and  gives  numerous  instances  of  its  successful  employment.  In  view 
of  these  facts,  it  appears  that  resection  of  the  knee  ioint  when  espe- 
cially undertaken  for  chronic  diseases  of  the  articulation,  or  even  for 
wounds  when  circumstances  admit  of  a  proper  "  after  treatment," 
has  been  successful  in  the  hands  of  civil  Surgeons. 


BISECTIONS  OF  KNEE  JOINT.  1  97 

The  conclusions  to  be  drawn  from  these  state- 
ments ami  arguments  seem  to  be  plainly  these  : 

1.  When  the  condition  of  the  patient  is 
good,  bis  hygienic  surroundings  unexception- 
able, and  the  proper  meaas  and  appliances  at 
band  for  the  subsequent  management  of  the  i 

the  Surgeon  is  justified  in  resorting  to  it,  particu- 
larly for  disease,  and  even  for  accidents. 

2.  When  the  condition  of  the  patient  is  bad,  and 
bis  hygienic  surroundings  exceptionable,  —  as 
when  exposed  to  the  vjtiated  atmosphere  of  cities, 
ill  regulated  camps,  and  crowded  hospitals — or 
more  particularly,  when  the  circumstances  of  the 
case  preclude  that  absolute  repose  of  mind  and 
body  so  indispensable  to  its  success,  theSurgeonis 
not  warranted  in  attempting  the  operation. 

3.  Resections  of  the  knee  joint  are  better  suited 
to  civil  than  to  military  practice. 

4.  Resection  of  the  knee  joint  should  not  take 
the.place  of  amputation  of  the  thigh,  in  the  lower 
third,  in  held  surgery,  because  of  the  impossibility 
of  maintaining  those  conditions  which  are  absolute- 
ly necessary  to  its  surer 

5.  Resection  of  the  knee  joint  may  be  resorted 
to  in  hospital  (military)  Service,  when  the  tone  of 
the  system  has  no1  beenloweredby  exposure,  priva- 
tion, or  disease,  and  an  abundance  of  pure  air  and 
nutritious  food  can  be  commanded,  provided  that 
permanency  ot  location,  constant  and  intelligent 
attention,  and  contentment  of  mind  on  the  part  of 
the  patient,  can  be  secured.    If  there  be  the  slight- 

>ubt  or  difficulty   in    regard    to  either  one  of 


198  RESECTION  OF  HIP  JOINT. 

these  prerequisites,  give  the  patient  the  benefit  of 
it,  and  amputate  the  limb.  Rernember  that  resec- 
tion of  the  knee  must  be  performed  primarily  or 
not  at  all. 

The  drain  upon  the  system  is  immense,  and  every 
possible  provision  should  be  made  for  sustaining 
and  invigorating  it  at  all  periods  in  the  history  of 
the  case. 

Resection  of  the  Hip  Joint. — Directions. — Make  a 
semi-lunar  incision,  beginning  at  the  anterior  su- 
perior spine  of  the  Ilium^  and  carrying  it  behind 
the  articulation  to  near  the  tuberosity  of  the  Is- 
chium ;  cut  a  large  flap  with  its  base  downwards 
through  the  muscles,  and  raise  it  so  as  to  show  the 
capsular  ligament  of  the  joint ;  divide  this  ligament 
thoroughly ;  flex  the  thigh  and  carry  it  inwards ; 
divide  the  round  ligament;  carry  the  knife  be- 
tween the  head  of  the  bone,  and  the  acetabulum, 
and  divide  the  soft  parts  behind ;  and  then  press 
the  head  of  the  bone  outwards  and  remove  it,  with 
the  saw.  This  being  done,  bring  the  flap  in  posi- 
tion, place  the  limb  on  the  double  inclined  plane, 
or  in  Smith's  anterior  splint ;  and  apply  cold  wa- 
ter dressings.  Convalescence  is  necessarily  slow, 
and  is  preceded  by  extensive  inflammation,  pro- 
fuse suppuration,  and  debility. 

Remarks. — This  operation  was  first  attempted  by 
White,  of  Manchester,  in  1769,  and,  it  is  said,  with 
success. 

Experience  has  demonstrated  that  resection  of 
this  joint  is  much  more  successful  wken  performed 
for  disease  than  for  injuries  ;  and  a  rule  has  been 
adopted  for  this  special  operation  among  military 


RESECTIONS  OF  HIP  JOINT.  I'.'!) 

Surgeons,  which  is  directly  opposed  to  that  estab- 
lished for  all  others,  viz  ;  for  hip  joint,  resection 
discard  the  "primary  operation,"  and  rely  exclu- 
sively upon  the  "  secondary."  The  most  fatal  re- 
sults will,  in  all  probability  ensue  from  haste,  while 
*  uothing»can  he  lost  by  delay.  Festindte  /iwfeisthe 
cardinal  principle  in  regard  to  resections  at  the 
coxo-femoral  articulation. 

This  is  a  dangerous  as  well  as  difficult  operation 
and  should  not  he  resorted  to,  save  as  the  alterna- 
tive of  an  amputation  in  the  upper  third  of  the 
thigh,  or  at  the  hip  joint. 

As  regards  the  propriety  of  this  operation,  it  is 
well  to  remark  that  the  sentiments  of  Surgeons 
are  divided.  The  following  statistical  table,  taken 
principally  from  Armand,  will  perhaps  aid  in  solv- 
ing the  difficult}", with  those  who  may  he  called  up- 
on to  decide  this  important  question. 

PRIMARY  RESECTIONS  AFTER  GUN-SHOT  AVOUNDS. 

Surgeons.        No.  operated  upon.      Ceres.     Deaths. 


Lair 

6 

0 

6 

( Jooper, 

2 

0 

ille, 

1 

0 

1 

Elutin, 

•> 

0 

2 

Sedillott, 

5 

0 

5 

Sorrell, 

1 

1 

0 

on, 

1 

0 

1 

Lilli  ! 

1 

0 

1 

Gnbiot, 

0 

3 

French  crim. 

servi< 

(1 

9 

Macleod, 

;> 

I 

4 

S 

1 

0 

1 

2  35 


200  RESECTIONS  OF  HIP  JOINT. 

To  this  frightful  record  may  he  added  a  case  re- 
corded by  Seuten,  in  1832,  in  which  death  followed 
the  operation.  It  is  plain  then  that  primary  ope- 
rations are  to  be  discarded,  and  that  these  are  not 
cases  for  field  surgery. 

The  statistics  of  operations  for  injury  show  fa-» 
vorable  results  as  compared  with  amputation 
of  the  the  thigh  near  the  hip  joint,  and  de- 
monstrate that  there  are  circumstances  under  which 
this  resection  may  be  properly  undertaken.  The 
rule,  therefore,  is  to  attempt  to  save  the  limb,  rely- 
ing upon  a  secondary  operation,  if  the  effort  prove 
abortive. 

The  greatest  trouble  is  in  the  treatment  after  the 
operation.  It  is  a  matter  of  prime  importance  to 
keep  the  limb  in  a  state  of  repose  ;  and  yet,  ar- 
rangements must  be  made  to  facilitate  those  move- 
ments, which,  in  the  necessary  changes  of  position, 
are  essential  to  the  patient's  comfort.  Violent  exten- 
sion, then,  is  both  unnecessary  and  injurious, — un- 
necessary because  it  is  useless  to  attempt  to  restore 
a  perfect  limb,  and  injurious  because  it  prevents 
those  movements  which  are  necessary  to  comfort 
and  recuperation.  To  meet  these  varied  indica- 
tions the  double  inclined  plane,  or,  better  still,  the 
anterior  splint  of  Professor  Nathan  E.  Smith,  of 
Baltimore,  should  be  applied.  These  appliances 
will  be  more  particularly  described  under  another 
head  but  it  will  not  be  inappropriate  to  say  in  this 
connexion,  that  the  latter  is  one  of  the  great  sur- 
gical improvements  of  the  present  century. 

"Whatever  the  nature  or  extent  of  the  injury,  or 
however  great  the  seeming  necessity  for  this  oper- 


RESECTIONS  OF  HIP  JOI*  T.  201 

atiou,  it  should  never  be  performed  in  any  Hospi- 
tal in  which  pyaemia,  hospital  gangrene,  erysip- 
elas, or  cholera  prevails  as  an  epidemic,  or  upon 
those  whose  systems  arc  below  the  standard  of 
health.    * 

The  following  principles  may  be  regarded  as  es- 
tablished in  regard  to  this  operation  : 

1.  This  operation,  though  dangerous  should  be 
preferred  to  amputation  of  the  thigh  above  the 
junction  of  the  upper  and  middle  third  of  the  fe- 
mur, or  at  the  hip  joint. 

2.  The  secondary  rather  than  the  primary  oper- 
ation should  be  preferred. 

3.  Nothing  is  lost  by  delay,  and  an  attempt  to 
save  the  limb. 

4.  Statistics  show  a  mortality  after  'primary  op- 
erations of  nearly  one  hundred  per  cent,  but  give 
somewhat  more  favorable  results  for  secondary. 

5.  It  is  necessary  to  keep  the  limb  in -repose  but 
to  provide,  at  the  same  time,  for  the  natural  and 

9sary  movements  of  the  patient.  These  two 
indications  are  best  accomplished  by  the  employ- 
ment oi'  Smith's  anterior  splint. 

6.  Xever  operate  unless  all  the  sanitary  condi- 
tions are  favorable,  or  when  there  are  ditticulties 
in  regard  to  transportation  or  subsequent  treat- 
ment. 

7.  Sustain  the  strength  of  the  patient  against 
the  immense  drain  upon  his  vital  resources  inei- 
dent  to  the  profuse  suppuration  following  the  op- 
eration. 

Resection  of  the  Ribs. — It  may  be  necessary 
to  repeat,  Richerand's  operation  for  resection  oi*  a 


202  RESECTIONS  OF  RIBS. 

rib,  though  the  Surgeon  is  seldom  called  upon  to 
do  so. 

Directions. — By  a  straight,  a  curved,  or  a  coni- 
cal incision  lay  bare  the  diseased  portion  of  the 
bone ;  divide  the  intercostal  muscles  above  aud 
below  the  rib  on  a  director  passed  under  them ; 
then  detach  the  pleura  from  the  bone;  and  saw 
through  the  bone  with  a  chain  saw. 

There  is  danger  of  hemorrhage  from  the  inter- 
costal artery ;  but  the  vessel  is  small  and  may  be 
readily  drawn  out  and  ligated. 

Resection  and  removal  of  the  Inferior  and  su- 
perior Maxillary  Bones. — These  operations  are  un- 
dertaken for  the  removal  of  the  principal  bones  of 
the  face,  when  attacked  by  malignant  disease  ;  and 
hence  they  do  not  particularly  concern  the  military 
Surgeon.  They  are  bloody,  tedious,  and  perhaps 
dangerous,  but,  both  as  regards  deformity  and  mor- 
tality, their  results  are  far  less  to  be  dreaded  than 
is  generally  supposed,  or  as  might  reasonably  be 
expected. 

Observations. — In  resections  art  should  not  only 
seek  to  remove  the  diseased  bones  but  to  repro- 
duce the  fragments  which  have  been  destroyed. 
That  this  is  possible  to  a  considerable  extent,  is 
established  alike  by  clinical  observation  and  the 
teachings  of  experimental  physiology.  A  fresh  im- 
petus has  been  given  to  these  investigations  by  the 
recent  researches  of  Dr.  Leopold  Olier,  of  Paris. 
His  conclusions  are  of  sufficient  importance  to 
justify  their  incorporation  into  the  substance  of 
this  volume.  The  following  is  the  substan 
them: 


REPRODUCTION  OF  BONE.  203 

1.  The  reproduction  of  bone  proceeds  from  the 
inner  surface  of  the  periosteum. 

2.  In  transplanting  portions  of  the  periosteum, 
bone  of  various  forms  and  dimensions  can  be  at- 
tained according  to  the  shape  and  position  of  the 
transplanted  flap. 

3.  Bones  thus  developed  are  not  simply  shape- 
less concretions  of  calcareous  matter :  they  con- 
sist of  true  bone  with  all  the  anatomical  charac- 
teristics of  that  tissue. 

4.  The  new  bone  is  developed  in  the  subperios- 
teal blastena,  which  exists  normally  upon  the  in- 
ner surface  of  the  periosteum. 

5.  This  blastema  consists  especially  of  free  nu- 
clei— enclosed  in  cells  floating  in  a  semi-liquid 
transparent,  or  firmly  granular  material,  and  min- 
gled more  or  less  with  fibrinous  elements. 

6.  The  sub-periosteal  product  which  is  observ- 
ed, within  the  first  few  days  following  the  trans- 
plantation, is  generally  cartilaginous  ;  but  the  suc- 
ceeding  development  of  bone  progresses  without 
this  intermediate  element,  ./j 

7.  An  analagous  membrane  is  found  after  a  time 
upon  the  surface  of  the  bone  from  which  the  peri- 

uni  has  been  removed. 
S.   When  a  bone  is  removed,  leaving  its  perios- 
teum attached  to  the  tissues  which  ordinarily  cov- 
er   its    surface,  at   the    end  of  a  certain  time,  this 
portion  of  the  bone  is  reproduced  to  a  greater  or 

extent. 

9.  Am  c  resection  of  the  articular extremeties  of 
the  two  contiguous  bones,  anew  articulation  is 
formed,  if  the  ea,  i  ligamentsare  left  entire; 


204  REPRODUCTION    OF  BONE, 

while  the  two  long  extremeties  are  remodeled  in- 
dependently of  each  other. 

From  these  observations,  it  is  conclusively  de- 
monstrated, that  the  preservation  of  the  periosteum 
is  of  the  highest  importance.  As  bone  can  be  pro- 
duced in  inferior  animals,  wherever  periosteum 
is  transplanted,  similar  results  may  be  expected  in 
man  by  retaining  portions  of  the  same  membrane. 
Alter  all  resections,  the  excised  portions  of  the 
bone  should  be  covered  with  periosteum  so  as  to 
ensure  their  speedy  union.  The  apparent  difficul- 
ties in  the  way  of  a  practical  illustration  of  these 
principles  should  not  deter  the  Surgeon  from  a  per- 
sistent effort  to  adhere  to  mem  in  as  much  as  they 
open  the  way  to  the  accomplishment  of  such  im- 
portant results  in  this  special  branch  of  Surgery. 

These  views  are  new,  startling,  and  in  direct  op- 
position of  the  accepted  dogmas  of  the  profession  ; 
but  they  certainly  merit  attention  and  considera- 
tion, as  the  land  marks  of  a  new  field  of  physiolog- 
ical research,  and  the  heralds  of  still  prouder  tri- 
umphs for  Surgical  eofcmce. 

Let  the  Surgeon  inlSperating  on  bony  tissue  re- 
member, then,  to  preserve  as  large  a  portion  of  the 
periosteum  as  possible,  in  as  much  as  no  possible 
injury  can  result  from  such  a  procedure,  and  if  the 
deductions  just  enunciated  be  correct,  a  most  im- 
portant desideratum  is  supplied  thereby.  The  ex- 
periment of  leaving  the  periosteum  intact,  might, 
perhaps,  he  tried  to  some  advantage  in  connexion 
with  the  operation  of  trephing  the  skull, — securing 
a  bony    covering  for  the  delicate  and  important 


REPRODUCTION  OF  BONE.  205 

parts  which  are  exposed  in  this  operation.  For  the 
facts  in  this  regard,  collected  by  my  friend  Sur- 
geon F.  Sorrell,  the  reader  is  referred  to  table  "G" 
of  the  appendix  to  this  volume. 


CHAPTER   V. 


HEMORRHAGE. 

Hemorrhage  may  be  Primary  or  Secondary,  ac- 
cording to  the  period  of  its  development. 

Primary  Hemorrhage. — A  flow  of  blood  may 
associate  itself  either  with  operations  or  with 
wounds.  When  it  takes  place  during  the  operation, 
or  in  a  short  time  subsequent  there  to,  or  when  it 
occurs  upon  the  first  receipt  of  an  injury  or  with- 
in a  few  hours  after  the  accident,  the  hemorrhage 
is  said  to  be  primary. 

It  is  produced,  under  these  circumstances,  either 
by  the  direct  section  of  the  vessel  by  the  amputa- 
ting knife  or  the  missile  causing  the  wound,  and  it 
is  instantaneous  or  delayed  according  to  the  extent 
of  shock  sustained  by  the  system,  or  the  condition 
of  the  artery  itself  subsequent  to  the  division  o* 
its  coats. 

All  Surgeons  have  observed  the  fact,  that  in  some 
instances  a  division  of  the  large  arterial  trunks  is 
followed  by  no  immediate  loss  of  blood,  and  that 
the  flow  is  not  only  occasionally  delayed,  but  even 
entirely  suspended.  This  is  observable  both  in 
amputations  and  in  wounds,  especially  of  a  con- 
tused character. 


HEMORRHAGE^ 

This  is  due  to  the  influence  of  two  causes,  which 
deserve  some  consideration  in  this  connexion,  viz." 
paralysis  of  the  vessel,  and  the  condition  of  its  in- 
ternal coat. 

1.  Paralysis  of  the  vessel. — The  influence  exci- 
ted by  the  nerves  upon  the  circulation,  was  pointed 
out  in  another  connexion.  It  will  suffice  for  the 
present  purposes  to  state  that  each  vessel  is  accom- 
panied by  nervous  filaments,  upon  the  integrity  of 
which  the  proper  performance  of  the  circulatory 
function  depends.  "When  these  filaments  are  so 
affected  by  any  disturbing  cause  as  to  become  bad 
conductors  of  nervous  influence,  the  flow  of  blood 
through  the  artery  is  interrupted  to  a  great  extent, 
and  even  suspended  entirely  in  some  instances, 
notwithstanding  the  propelling  power  of  the  heart 
which  supplies  the  vis-a-tergo.  AVhcn  therefore  an 
artery  is  severed  under  those  circumstances,  or 
when  the  vessel  is  divide  by  an  agency  which  at 
the  same  time  paralizes  it,  there  is  either  no  hemor- 
rhage from  it,  or  the  blood  flows  in  a  very  small 
quantity. 

2.  The  Condition  oftlic  Internal  Coat  of  the  Ar- 
tery.— If  a  cylinder  of  paper  be  covered  internally 
with  a  coat  of  varnish,  and  then  suddenly  and  for- 
cibly put  upon  the  stretch,  an  examination  will  dis- 
cover an  immense  number  of  points  at  which  this 
internal  coating  has  been  fractured.  Thearteries 
are  lined  with  a  tunic  equally  as  delicate  and  fria- 
ble, and  when  rudely  stretched  or  torn,  as  occurs 
iu  connexion  with  lacerated  wounds,  this  internal 
tonic  sutlers  fracture  ai  a  number  of  points  through- 
out its  course.     At  each  point  of  fracture  coagula] 


208  PRIMARY    HEMORRHAGE. 

tion  and  effusion  takes  place,  tending  to  arrest  the 
blood  current.  This  taken  in  conj  unction  With  the 
paralysis  of  the  vessel,  accounts  for  the  fact  that  in 
some  instances  there  is  no  hemorrhage,  even  when 
large  arteries  are  severed,  in  connexion  both  with 
operations  and  wounds. 

Primary  hemorrhage  frequently  relieves  itself 
by  inducing  syncope — a  condition  in  which  there  is 
such  a  stasis  of  blood  in  the  divided  part  as  ad- 
mits of  the  formation  of  clots  and  ensures  the  com- 
plete blocking  up  of  its  vessels. 

The  flow  of  blood  may  take  place  from  the  ar- 
teries, the  veins,  or  the  capillaries,  while  the  soft 
parts  generally  or  the  bony  tissues  exclusively  may 
be   the  seat  of  the  hemorrhage. 

The  Blood  from  an  artery  is  of  a  vermillion 
color,  and  flows  by  jets  which  are  synchronous 
with  the  contractions  of  the  left  ventricle.  It  may 
come  either  from  the  proximal  or  the  distal  end 
of  the  vessel,  but  generally  from  the  former. 

The  blood  from  a  vein  is  of  a  dark  color  and 
flows  in  a  uniform  stream.  Usually  it  simply 
wells  out,  but  when  there  is  pressure  as  from  a 
ligature,  when  the  position  of  the  part  causes  the 
fluid  to  gravitate  towards  it,  or  when  the  contrac- 
tion of  the  muscles  constringes  the  vessel,  the 
blood  may  be  driven  out  with  some  force. 

The  blood  from  the  capillaries  is  neither  so 
bright  as  that  from  the  arteries  nor  so  dark  as 
that  from  the  veins,  and  oozes  out  rapidly,  it  may 
ba,  but  with  no  force. 

Hemorrhage  may  arrest  itself  spontaneously,  by 
inducing  syncope,  or  it  may  cause  the  speedy  death 


PRIMARY  HEMORRHAGE.  200 

of  the  patient  by  deprivingthe'great  centres  oi"  their 
"  life  which  is  the  blood." 

If  tho  quantity  of  boocl  lost  be  very  great  but 
still  not  sufficient  to  produce  death,  and  particu- 
larly if  it  be  spread  over  a  considerable  interval  of 
time,  a  state  of  anaemia  will  be  induced,  character- 
ized b}<  pallor  of  the  skin,  palpitation  of  the  heart? 
rushing  noises  in  the  head,  muscular  debility  a  ten- 
dency to  syncope,  oedema  of  the  lower  extremeties, 
and  a  general  impairment  of  all  the  functions. 

From  this  state  the  patient  sometimes  rapidly 
recovers,  the  vital  fluid  being  speedily  reproduced, 
and  the  organism  readily  returning  to  its  normal 
tone  and  standard  of  health. 

It  not  unfrequently  happens,  however  that  tkis 
state  of  anaemia  becomes  the  settled  habit  of  the 
system  and  continues  for  a  long  period,  being  ac- 
companied by  great  debility  and  disturbance  of 
function. 

Hemorrhagic  fever  may  also  manifest  itself  aft  A 
great  loss  of  blood,  characterized  by  a  tendency  to 
reaction,  with  extreme  irritability  of  the  heart  and 
arteries.  This  is  nothing  more  or  less  than  fever  as- 
sociated with  anamia,  as  the  symptoms  plainly  in" 
dicate. 

Hemorrhage  may  be  delayed  until  reaction  en- 
sues. The  current  of  blood  which  has  suffered  a 
temporary  arresl  under  the  shock  induced  by  the 
injury  or  operation,  may  be  driven  by  the  more 
violent  contra  'thehearfj  through  the  v 

notwithstanding  the  obstructions  to  its  passage, 
and  lost  in  large  quantities^cotemporaneously  with 
the  development  of  reaction  in  the   system.     This 


210  SECONDARY  HEMORRHAGE. 

usually  occurs  within  the  first  thirty-six  hours, 
and  may  justly  be  regarded  as  a  primary  hemor- 
rhage. 

Secondary  Hemorrhage. — As  that  hemorrhage 
which  occurs  before  the  development  of  inflam- 
mation is  styled  primary,  so  that  which  occurs  af- 
ter that  proeess  has  been  established  is  denomina- 
ted secondary.  It  may  associate  itself  either  with 
inflammatory  fever,  sloughing  or  ulceration,  but 
as  regards  the  time  of  its  occurrence,  is  always 
subsequent  to  the  inflammatory  reaction: 

It  is  now  generally  agreed  anions:  Surgeons 
that  any  flow  of  blood  which  takes  place  after  the 
thirty  sixth-hour  succeeding  an  operation  or  an 
injury  is  to  be  regarded  as  a  secondary  hemor- 
rhage and  should  be  treated  immediately  as  such 
upon  the  principles  which  will  be  discussed  here- 
after. 

A  patient  upon  whom  an  operation  has  been 
performed,  or  who  has  received  a  wound  of  any 
magnitude  can  never  be  regarded  as  beyond  the 
possibility  of  this  accident  until  the  work  of  cica- 
trization is  complete.  From  the  first  cut  to  the 
last  dressing — at  any  period  in  the  history  of  the 
case — hemorrhage  is  liable  to  occur,  endangering 
life  and  calling  for  the  exhibition  of  skill  and 
courage  on  the  part  of  the  Surgeon. 

The  period  at  which  secondary  hemorrhage 
most  likely  to  occur  is  still  a  matter  of  dispute. 
Guthrie  affirms  that  it  is  between  the  eighth  and 
twentieth  day  ;  Dupuytren  thinks  it  is  from  the 
tenth  to  the  twentieth  day  ;  Henman  sets  it  down 
as  from  the  fifth  to  the  eleventh ;  Roux  trom  the 


and 

re  is 


CAUSES   OF   HEMORRHAGE.  211 

sixtli  co  tho  twentieth;  and  Macleod  from  tlio 
fifth  to  the  twenty-fifth.  It  has  been  known,  how- 
pver,  to  occur  as  late  as  the  seventh  wgek,  even 
without  the  existence  of  gangrene  or  ulceration, 
though  after  the  twenty-fifth  day  it  is  fair  to  pro- 
nounce the  patient  in  a  great  measure  over  his 
danger. 

This  accident  may  arise  from  a  variety  of  cir- 
cumstances, connected  with  wounds  and  opera- 
tions. 

In  connexion  with  wounds  it  proceeds  from — 

1.  The  separation  of  the  eschar. 

2.  Injury  by  fractured  bones. 

3.  The  erosion  or  tearing  of  the  vessel.  • 

4.  Relaxation  of  the  capillaries  produced  by 
general  feebleness  of  the  patient. 

5.  Ulceration  either  incidental  or  accidental. 

6.  Gangrene. 

7.  Development  of  tho  collateral  circulation  and 
the  patulous  condition  of  the  distal  orifice. 

In  connexion  with  operations  it  may  be  the  pro- 
duct of  the  following  causes  : 

1.  Those  wl licit  are  connected  with  the  condi- 
tion of  the  artery. 

2.  Those  which  are  connected  with  the  ligature 
itself, 

3.  Those  which  are  connected  with  tho  condition 
of  the  blood. 

4.  Those  which  are  connected  with  the  system 
at  large. 

1.  Causrs  which  are  connected  with,  the  condi- 
tion of  the  artery.  The  different  coats  of  the  ar- 
tery are  subject  to  diseases  of  various  kinds,  and 


212  CAUSES  OF  HEMORRHAGE. 

when  so  affected,  there  will  ensue  rapid  sloughing 
and  ulceration  of  the  vessel  at  the  point  of  liga- 
tion, and  a  consequent  escape  of  blood.  Again  it 
frequently  occurs  that  an  atheromatous  or  calcari- 
ous  deposit  has  developed  itself  in  the  artery,  ren- 
dering it  brittle,  and  causing  it  to  give  way  within 
a  day  or  two  succeeding  the  operation.  So,  like- 
wise, when  the  arteries,  in  common  with  all  other 
structures  of  the  organism,  have  yielded  to  the  en- 
ervating influences  of  asthenic  diseases,  insufficient 
diet,  and  such  agencies  as  tend  to  diminish  vital 
power  and  to  retard  nutrition,  the  ligature  readily 
divides  the  weakened  coats  of  the  vessel,  and  per 
mits  the  escape  of  its  contents.  The  slight  wound- 
ing of  the  artery  abovo  the  ligature,  or  even  of  one 
of  its  smallest  branches,  may  produce  secondar 
hemorrhage.  But  the  most  frequent  cause  of  hem- 
orrhage which  manifests  itself  in  this  connexion, 
originates  in  the  patulous  condition  of  the  lower 
orifice  of  an  artery  which  has  been  accidentally 
divided — a  condition  which  results  from  the  divi- 
sion of  the  nervous  filaments  distributed  to  the 
vessel,  and  at  the  same  time  invites  the  escape  of 
its  blood. 

2.  Causes  which  associate  themselves  ivith  the  liga- 
ture itself.  These  may  depend  either  upon  the  na- 
ture of  the  material  employed,  or  upon  the  man- 
ner of  its  application.  Thus,  as  has  been  already 
shown,  some  substances  are  more  irritating  to  the 
tissues  than  others,  and  by  developing  too  much 
inflammation  in  the  coats  of  the  artery,  cause  their 
disruption,  and  the  development  of  hemorrhage. 
Again  if  the  ligature  be  tied  too  loosely,  or  with 


• 


CAUSES   OF   HEMORRHAGE.  213 

the  inclusion  of  a  piece  of  nerve,  vein,  or  muscle, 
so  as  to  become  loose  after  suppuration  has  ensued, 
the  blood  readily  and  rapidly  escapes.  It  often 
happens,  that,  either  from  some  anomalous  devel- 
opment of  brandies,  or  the  ignorance  of  the  oper- 
ator, the  ligature  is  tied  too  near  to  a  collateral 
branch  above,  so  that  the  condition  of  quiescence 
so  essential  to  the  production  of  a  firm  coagulum, 
cannot  be  obtained,  and  the  plugging  up  of  the  ar- 
tery is  not  effected.  Under  these  circumstances 
the  blood  ma}'  escape  at  any  time,  causing  great 
trouble  and  inconvenience,  and  seriously  endanger- 
ing the  life  of  the  patient. 

3.  Causes  which  connect  tfa  mSi  Ives  with  the  condi- 
tion of  the  blood.  It  has  been  seen  that  the  formation 
and  organization  of  a  clot — of  a  firm  and  adequate 
coagulum — is  essential  to  the  complete  and  per- 
manent closure  of  the  artery.  Physiology  teaches 
that  the  blood  coagulates  much  better  at  some 
periods  than  at  others,  and  that  this  difference  de- 
pends upon  certain  intrinsic  changes  which  take 
place  in  the  circulating  fluid  itself.  The  blood 
must  contain  a  certain  amount  of  fibrine  and  red 
corpuscles — must  be  in  the  possession  of  its  normal 
and  healthful  constituents,  in  order  to  ensure  its  rea 
dy  coagulation,  whether  within  or  without  the  body- 
audit  must  follow,  therefore,  that  alterations  in  these 
elements,  both  as  to  quantity  and  quality,  have  a 
material  though  indirect  influence  in  the  develop- 
ment of  secondary  Hemorrhage.  Experience  has 
shown  that  violent   i  i;v   when   ac- 

companied by  nervous  excitement,  tends  to  liquify 
the  blood  and  to  interfere  with  its  coagulability 
9b  b  • 


214  CAUSES    OF    HEMORRHAGE. 

Should  not  this  fact  furnish  a  hint  to  Surgeons,  as 
regards  the  treatment  of  wounded  arteries,  upon  the 
battle  field  ? 

4.  Causes  which  connect  themselves  loith  the  system 
at  large.  All  material  changes  in  the  blood  either 
depend  upon  or  induce  certain  alterations  in  the 
system  at  large;  and  to  that  extent  this  division  of 
the  causes  which  produce  Hemorrhage,  belongs 
properly  to  the  last  head.  There  are  other  states  of 
the  system,  however,  which  exercise  a  more  direct 
influence  in  the  induction  of  this  accident,  and 
which  should  be  considered  in  this  connexion. 

It  is  not  only  necessary  that  a  firm  coagulum 
should  form  within  the  vessel,  but  the  outer  coat 
must  be  reinforced  by  a  deposit  of  plastic  lymph 
in  order  to  prevent  its  rupture.  A  certain  amount 
of  normal  and  healthful  adhesive  inflammation  is 
essential  to  the  perfection  of  this  process, — which  is 
impossible  in  certain  diseased  states  of  the  system, 
as  when  a  tendency  to  erysipelas,  phlebitis,  suppura- 
tion, albuminuria,  pyaemia,  &c,  exists. 

Although  secondary  Hemorrhage  may  occur  at 
any  time  in  the  history  of  the  case,  there  are  three 
■periods  at  which  it  is  particularly  likely  to  be  de- 
veloped, viz:  1  Within  a  few  clays  after  the  appli- 
cation of  the  Ligature,  2  When  the  Ligature  se- 
paiates;  and  3.  At  an  indefinite  time  after  its  separa- 
tion. 

1.  Within  a  few  days  after  the  application  of  the 
Ligature. — The  bleeding  which  appears  at  this  period 
results  from  the  improper  tying  of  the  artery;  some 
disease  or  defect  in  its  coats;  from  the  development 


PERIOD  OF  OCCURRENCE.  215 

of  the  collateral  circulation,  and  the  escape  of  the 
blood  through  the  patulous  orifice  of  the  distal  end 
of  the  artery;  and  from  the  want  of  proper  adhesive 
inflammation,  &c. 

2.  When  the  Ligature  separates  and  comes  a- 
way. — This  Hemorrhage  may  be  occasioned  by  any 
one"  of  the  causes  above  mentioned;  but  is  mainly 
due  to  the  improper  development  of  the  internal 
coagulum,  and  to  the  absence  of  the  rcenforcement 
which  the  external  coat  requires  to  enable  it  to 
sustain  the  great  burden  imposed  upon  it. 

3.  After  the  liyature  has  separated. — Hemorrhage 
may  appear  at  any  period  between  the  separation 
of  the  ligature  ami  the  cicatrization  of  the  wound. 
This  is  usually  the  result  of  the  absorption  both  of 
the  internal  coagulum,  and  the  lymph  by  which  the 
external  coat  has  been  strengthened. 

Treatment. — The  treatment  of  Hemorrhage  con- 
sists essentially  in  preventing  or  arresting  the  flow 
of  blood,  and  is  modified  by  the  variety,  seat  and 
source  of  the  flow. 

Treatment  of  Primary  Hemorrhage. — The  moans 
employed  for  the  control  of  hemorrhage  are  sus- 
ceptible of  division  into  two  classes,  viz:  Preven 
tive  and  Curative  measures — the  one  being  em" 
ployed  in  advance  to  prevent  the  flow  and  the  other 
afti  r  the  appearance  of  the  Hemorrhage,  to  restrain 
it. 

Preventive  measures. —  These  embrace  compres- 
sion, position,  and  arterial  sedatives. 

ipivssiou. — The  low  of  blood  can  be  prevented 
in  most  cases  by  shutting  off  the  supply  by  means 
of  compression  made  upon  the  artery  between  the 


216  PRETENTIVE  MEASURES. 

locality  of  the  accident  and  the  part.     It   may  be 
Digital  or  Instrumental. 

Rules  for  Digital  Compression. 

1.  Find  the  artery,  select  the  point  for  compres- 
sion, and  see  that  the  thumb  and  fingers  are  applied 
forcibly  upon  the  vessel. 

2.  Apply  the  thumb  across  the  vessel  like  a  seal  • 
or  if  the  fingers  be  employed  form  a  horizontal 
plane  with  their  united  pulps  and  range  them  along 
the  course  of  the  artery. 

The  thumb  is  placed  upon  the  opposite  side  and 
made  to  constitute  a  fixed  point  upon  the  limb. 

3.  Press  just  hard  enough  to  destroy  the  pulsa- 
tion in  the  vessel,  and  when  the  fingers  become  tired, 
aid  them  with  those  of  the  other  hand. 

4.  Pressure  should  be  made  perpendicularly  to 
the  artery. 

5.  When  a  jet  of  blood  is  required,  so  as  to  enable 
the  Surgeon  to  recognize  the  vessel,  the  fingers  can 
be  slightly  raised,  without  letting  the  artery  escape, 
and  then  reapplied. 

The  advantages  of  digital  compression  are,  these 
viz:  the  venous  current  is  not  arrested;  pressure  "is 
only  made  upon  one  point;  and  the  artery  can  be 
always  discovered  by  the  sense  of  touch. 

Instrumental  compression  is  accomplished  by 
means  of  a  key,  the  winch,  the  tourniquet,  &c. 
The  key  may  be  employed  for  compressing  nearly 
all  the  arteries,  especially  the  subclavian.  When 
used  it  should  be  well  padded  and  applied  directly 
across  the  track  of  the  artery  and  not  too  firmly 
pressed  upon  it. 

The  Winch  may  be  used  in  cases  of  absolute  ne- 


PREVENTIVE   MEASURES.  217 

y,  but  it  is  objectionable  because  it  compresse 
the  veins,  ami  cannot  readily  be  relaxed  or  lightened 

The  Tourniquet  of  Petit.  This  consists  of 
three  parts,  viz:  the  pad  to  compress  the  artery — 
which  should  be  firm  narrow  and  flat; — a  strong 
band  to  embrace  the  limb;  and  a  screw  by  which 
this  band  is  tightened,  and  the  artery  more  firmly 
coin | ■.  The  Tad  should. be  so   placed    as   to 

compress  the  artery  against  the  bone ;  and  the  screw 
turned  lightly  until  the  first  incisions  are  made,  or, 
what  is  better  still,  until  hemorrhage  from  the 
artery  demands  some  additional  assistance  for  its 
restraint. 

The  advantages  of  the  tourniquet  are  that  it  can 
be  more  readily  used  by  the  ignorant — the  patient 
himself  being  able  to  manage  it  properly-;  it  ensures 
a  more  reliable  and  permanent  pressure;  it  com- 
presses all  the  branches  of  the  artery  as  well  as  the 
main  trunk  itself; — it  never  tires,  as  do  the  fingers  ; 
it  controls  hemorrhage  as  well  in  anomalous  bifur- 
cations and  distributions,  as  under  ordinary  cir- 
cumstances, and  it  presses  upon  the  neves  and 
thus,  to  some  extent,  diminishes  the  sensibility  of 
the  part. 

The  disadvantages  of  this  instrument  are  that,  it 
interferes  with  the  venous  circulation,    and   by  ac- 
cumulating blood  in  the  part,  causes  a  great  loss  of 
that  fluid  during  an  operation;  and  that  it  may  in_ 
s  mortification  if  ignorantly  or  too  persistently 
employed,    by  paralyzing  the  nerves  beneath  it  so 
lower  the  vital  energies  of  tin'  tissues  to  which 
fchey  are  distributed,  and  by  cutting  oil*  the  sup- 
;'  arterial  blood. 


218  PREVENTIVE    MEASURES. 

The  Tourniquet  of  Siguori. — This  instrument 
consists  of  an  arc  of  steel  with  a  joint  in  the  mid- 
dle and  a  screw  by  which  the  padded  extremities 
of  the  instrument  are  pressed  together.  One  of 
these  pads  can  be  applied  directly  over  the  artery, 
selecting,  if  possible,  some  point  above  the  bone 
and  the  other  on  the  opposite  side  of  the  limb. — 
By  turning  the  screw  the  necessary  amount  of  ex- 
tension is  made. 

The  advantages  of  this  instrument  are,  that  the 
compression  can  be  rapidly  taken  from  the  artery, 
and  that  as  only  two  points  of  the  limb  are  com- 
presssed,  the  venous  circulation  is  not  interrup- 
ted. 

The  objections  to  it  are,  that  the  pad  is  likely 
to  roll  off  the  artery  as  the  screw  is  turned,  and 
that  in  relaxing  it,  the  position  of  the  whole  in- 
strument is  frequently  so  much  changed  as  to  ren- 
der a  fresh  search  for  the  artery  necessary. 

The  ligature  en  masse  of  Mayor,  the  compressor 
of  Dupuytren,  and  other  similar  instruments  are 
generally  abandoned. 

Comjwession  of  Particular  Arteries. — The  primi- 
tive carotid  may  be  compressed  just  above  the 
omo-hyoid  muscle,  against  the  cervical  vertebrae, 
by  means  of  the  fingers,  applied  perpendicularly. 

The  facial  artery  may  be  readily  compressed  by 
the  finger  on  the  border  of  the  lower  jaw,  just  in 
front  of  the  masseter  muscle. 

The  temporal  artery  may  be  readily  compressed 
at  a  point  in  frOnt  of  the  external  ear,  two  inches 
from  the  base  of  the  tragus,  by  means  of  perpen- 
dicular pressure  made  with  the  fingers.     Hemor- 


COMPRESSION  OF  ARTERIES.  219 

rhage  from  this  artery  may  be  checked  by  employ- 
ing a  common  tailor's  thimble  and  applying  a  com- 
press over  it. 

The  subclavian  artery  may  be  compressed  by 
means  of  a  key  or  other  similar  instrument,  well 
padded  and  applied  at  a  point  where  the  vessel 
passes  over  the  first  rib,  just  above  the  clavicle  and 
external  to  the  scalenus  muscle.  Unless  the  pa- 
tient is  thoroughly  under  the  influence  of  chloro- 
form, this  procedure  cannot  be  relied  on  to  tke  ex- 
clusion of  other  measures. 

The  axillary  artery  may  be  compressed  under 
the  clavicle,  and  against  the  second  and  third  ribs, 
but  a  complicated  apparatus  is  necessary,  and  the 
difficulties  are  great.  It  may,  however,  be  easily 
pressed  against  the  head  of  the  humerus,  by  means 
of  four  lingers  only  or  with  the  addition  of  a  cush- 
on.  The  point  of  compression  is  at  the  union  of 
the  anterior  and  middle  third  of  the  axilla. 

The  brachial  artery  may  easily  be  compressed  by 
the  fingers  or  tourniquet,  against  the  humerus,  at 
any  point  along  the  border  of  the  coraco-braehialis 
above,  and  the  biceps  farther  down.  There  arc 
several  important  nerves  which  accompany  this  ar- 
tery, and  if  the  pressure  is  continued  too  long,  the 
patient  suffers  great  pain.  This  artery  should  be 
compressed  in  all  operations  on  the  upper  extrem- 
ity, below  the  insertion  of  the  latissimus  dorsi 
muscle,  save  those  of  the  hand  and  fingers,  ami 
sometimes  in  those  if  (lie  pressure  made  upon  the 
radial  and  ulna  arteries  is  not  sufficient  to  restrain 
the  hemorrhage. 
The  radial  artery   is   easily  compressed  at  the 


220  COMPRESSION  OF  ARTERIES. 

lower  third  of  the  fore  arm,  between  the  radius 
and  the  tendon  of  the  flexor  carpi  radialis,  just 
where  the  pulse  is  felt. 

The  ulna  artery  may  be  reached  at  the  inferior 
third  of  the  arm,  by  pressing  the  flexor  carpi-ulna- 
ris  against  the  ulna. 

The  external  iliac  may  be  compressed,  in  ex- 
treme cases,  by  pressing  it  against  the  brim  of  the 
pelvis,  through  the  abdominal  paricles. 

The  femoral  artery  may  be  compressed  in  two 
places,  viz  :  upon  the  pules,  and  in  the  middle  third 
of  the  limb. 

This  is  accomplished  upon  the  pubes,by  pushing 
it  forcibly  with  the  thumb  or  fingers  against  the 
pectineal  eminence.  The  pressure  should  be  made 
obliquely,  ujywards  and  backwards,  forming  with  the 
horizon  an  angle  of  45°.  This  compression  is  safe 
easy,  and  much  used  in  all  operations  upon  the 
lower  extremities. 

In  the  middle  third  of  the  limb  it  may  be  readily 
compressed  against  the  femur,  by  means  of  the 
tourniquet,  and  even  the  fingers,  taking  care  to 
flatten  the  artery  against  the  bone.  This  is  much 
used  in  all  operations  on  the  lower  extremities  save 
at  the  hip  joint  [[and  upper  third  of  the 
thigh. 

The  popliteal  artery  may  be  compressed  opposite 
the  joint,  either  by  means  of  the  tourniquet  or  the 
finger 

The  anterior  tibial  artery  may  be  compressed  by 
forcing  it  against  the  tibia  at  any  point  from  the 
middle  of  the  leg  to  the  termination  of  its  course- 
It  is  to   be   found  on   the  side  of  the   extensor 


I-OPTTION.  221 

proprius-pollicis*tendon.  Compression  of  this  aiv 
tery  is  not  of  much  impo*rtauce  so  far  as  amputa- 
tions are  concerned, — the  femoral  being  com- 
pressed in  all  operations  upon  the  lower  extremi- 
ties. 

The  posterior  tibial  may  be  compressed  in  the 
lower  third  of  the  leg,  at  any  point  parallel  with 
the  inner  margin  of  the  tendo-Achilis,  and  also  be- 
hind the  inner  ankle,  where  it  is  very  superficial — 
not  much  employed  for  the  reason  given  above. 

Position. — As  a  means  of  preventing  concurrent 
hemorrhage,  position  may  be  employed  to  consid- 
erable advantage.  It  is  manifest  that  the  normal 
position  is  best  adapted  to  the  necessities  of  the 
animal  economy,  and  that  while  the  course  of  the 
principal  venous  trunks  is  perpendicularly  up- 
wards, the  amount  of  blood  carried  from  the  ex- 
tremities, bears  a  certain  relation  to  the  wants  of 
the  various  tissues  to  which  the  arteries  have 
transported  it.  A  greater  amount  of  the  circula- 
tory fluid  must  therefore  remain  in  the  parts  con- 
cerned so  long  as  this  erect  position  is  preserved, 
than  when  the  vessels  are  turned  perpendicularly 
downwards,  and  the  force  of  gravity  is  superadded 
to  the  influences  which  normally  operate  in 
returning  the  blood  from  the  extremities  towards 
the  trunk.  The  same  principles  apply  to  arteries, 
but  inversely, — the  force  of  gravity  acting  as  some 
restraint  upon  the  heart's  action,  and  in  a  measure 
controlling  the  circulation. 

Thc<e  facts  may  be  employed  to  advantage  in 
the  restraint  of  hemorrhage  from  wounds  ;  and  the 
elevation  of  the  affected  part  should  be  attempted 


222  position. 

among  the  earliest  measures  employed  by  theSur- 
geon. 

In  primary  operations  also,  when  the  Surgeon 
has  leisure  to  devote  to  the  work,  an  attempt  should 
be  made  to  diminish  the  amount  of  blood  in  the 
condemned  member  and  to  relieve  the  venous 
trunks  and  capillaries  to  some  extent,  by  reversing 
the  position  ot  the  part  for  some  moments  be- 
fore the  incisions  are  made.  In  "  secondary  am- 
putations," this  should  invariably  be  done,  as  there 
is  always  time  enough  to  spare  for  this  procedure, 
and  the  hypertrophied  condition  of  the  vessels  in- 
creases its  importance. 

In  all  operations  upon  drunkards  this  should  be 
an  indispensable  preliminary  on  account  of  the  ex- 
traordinary stasis  of  blood  in  the  capillaries  of  such 
persons,  and  the  tendency  to  hemorrhage  from  that 
cause.  To  such  a  degree  does  this  capillary  con- 
gestion exist  in  some  cases — and  it  is  present  in 
all — that  the  simple  operation  of  cupping,  or  the 
application  of  leeches,  induces  an  oozing  from 
these  delicate  vessels  of  so  persistent  a  character  as 
to  defy  all  ordinary  remedies  and  to  jeopardizethe 
patient's  life. 

Arterial  Sedatives. — These  actby  diminishing  the 
the  amount  of  blood  sent  to  the  part  by  its  propelling 
organ.  To  this  class  belong  digitalis,  veratrum,  vir- 
ide,  tart,  emetic,  and  all  those  agents  which  directly 
or  indirectly  control  the  hearts  action.  They  may  be 
emploj'ed,  with  particular  advantage,  when  the 
necessities  of  the  case  demand  an  amputation  and 
during  the  existence  aud  manifestation   ot  fibrile 


ARTERAL  SEDATIVE8.  223 

phenomena.     The  subject  demands  a  more  thorough 
investigation  at  the  hands  of  the  profession. 

Curative  measures. — By  this  term  is  meant  all 
those  agents  which  are  employed  for  the  arrest  of 
hemorrhage  after  it  has  been  developed.  These 
vary  according  to  the  vessel  which  is  the  source  of 
the  flow  as  it  comes  from  arteries,  veins  capil- 
laries. 

Bleeding  from  the  veins,  generally  ceases  spon- 
taneously or  is  readily  controlled  by  pressure.  It 
■  js  best  to  avoid  applying  ligatures  to  veins  when 
the  operation  can  be  avoided,  on  account  of  the 
danger  of  phlebitis,  though  it  may  be  necessary 
when  they  are  diseased  or  when  they  have  been 
opened  obliquely  by  wounds  or  in  operations.  Thig 
variety  of  hemorrhage  results  either  from  mechani- 
cal obstruction  to  the  return  of  the  blood  to  the 
heart;  from  the  violent  struggles  of  the  patient 
whereby  it  is  prevented  from  flowing  freely  through 
the  lungs  and  larger  veins;  and  from  unnatural 
enlargement  of  the  veins  themselves — which  in. 
d#rcs  a  retention  of  blood  within  them.  If  the 
blood  flow  freely  from  a  large  vein  during  an  oper- 
ation, it  may  be  arrested  either  by  plugging  up  the 
vessel  with  the  finger,  or  applying  a  sponge  saturat- 
ed with  cold  water,  and  taking  oil  the  compression 
above — i.  e.  relaxing  the  tourniquet,  &c.  Should 
the  flow  be  influenced  by  the  struggles  of  the 
patient,  a  more  liberal  administration  of  Chloro- 
form will  greatly  tend  to  arygst  it,  by  removing  its 
cause!  In  the  event  of*  -p\\t\Q^re  to  arrest  the 
hemorrhage  by  these  mA  *  0  o^ourse  may  be  had 
to  the  various  remedies  <     i^-c/ting  bleeding  from 


DLO\ 


•1V-V 


224  CURATIVE  MEASURES. 

capillaires  and  arteries,  which  will  be  considered  a^ 
length  below. 

Bleeding  from  the  capillaires  may  occur  either 
from  the  unnatural  development  of  these  vessels, 
from  an  unusual  stasis  of  blood  in  them,  and  fpom 
a  disproportionate  activity  between  the  arteries 
and  veins.  These  vessels  are  usually  compressed 
by  the  retraction  of  the  tissues,  but  it  sometimes 
happens  that  the  blood  continues  to  flow  in  streams, 
greatly  to  the  danger  of  the  patient  and  to  the  con- 
fusion of  the  operator. 

The  means  used  to  arrest  the  flow  of  blood  from 
the  cappillaires  are : 

1.  Compression  by  means  of  the  fingers  and 
bringing  the  flaps  together. 

2.  Cold  water  applied  either  by  means  of  a 
sponge  or  poured  from  a  vessel. 

3.  Styptics  proper,  such  as  powdered  ice,  evapor- 
ating lotions  of  water  and  alcoholic,  camphor  in 
powder  or  between  two  damp  cloths,  matico,  ergo- 
tine,  &c. 

4.  Absorbents — as  lint,  agaiic,  spiders  Mb 
powdered  gum  arabic,  flour,  and  rosin. 

5.  Astringents, — including  all  of  vegetable  origin, 
either  in  solution  wder,  also  alum,  sulphate  of 
iron,  chloride  of  i.  hate  of  copper,  nitrate  of 
silver,  vinegar  aur^  j  n  juice,  creosote  and 
water,  sol.  surf1  iron,  muriated  tincture 
of  iron,  and  com                 icture  of  benzoin. 

6.  Cauterizati  ,3  resorted  to  when  otlier 
means  have  faile  ' -actual  cautery  should  be 
used  under  the;  jtances.  Heat  the  iron  to 
whiteness,  and  <.  .t  a  short  time  to  the  part? 


CURATIVE  MEASURES.  225 

taking  care  not  to  bring  away  the  eschar,  and  thus 
to  defeat  the  objects  of  its  application. 

Bleeding  from  the  arteries  is  of  most  frequent 
occurrence,  as  it  is  the  source  of  greatest  danger  to 
the  patient.  The  means  at  the  command  of  the 
Surgeon  for  the  arrest  of  the  flow  of  blood  which 
occurs  during  an  operation  or  immediately  subse- 
quent to  it.  are  numerous.  The  following  are  most 
worthy  of  confidence : 

Direct  Compression. — This  consists  in  the  ap- 
plication of  the  finger  to  the  orifice  of  the  bleeding 
vessel  until  compression  can  be  established  above 
or  the  operation  completed. 

Indirect  Compression. — This  consists  in  seiz. 
ing  the  vessel  between  the  fingers,  or  grasping  it 
firmly  with  the  hand.  This  is  chiefly  practised  in 
flap  operations,  and  especially  in  amputations  at  the 
hip  and  shoulder  joints.  The  old  method  of 
ligating  the  femoral  artery,  before  commencing 
the  amputation,  was  always  opposed  by  the  best 
practical  Surgeons,  and  is  now  considered  obso- 
lete,—  the  method  of  indirect  compression  by  the 
hands  of  an  assistant,  following  the  knife  and  grasp- 
ing the  artery  immediately  after  its  division,  is  now 
universally  recognized  as  the  proper  procedure. 
In  operations  at  the  shoulder  joint  the  main  re- 
liance of  the  operator  must  he  upon  immediate 
compression  of  the  artery  by  hi.-  assistant  as  the 
last  flap  is  cut,  rather  thai1,  upon  pressure  above 
the  claricle.  The  artery  may  also  be  compress- 
ed by  the  application  of  the  ordinary  forceps 
with  hooked  extremities  and  a  spring  catch,  or 
a  forcep   with  flattened  extremities,  which  cl 


226  CURATIVE    MEASURES. 

by  its  own  spring,  and  is  opened   by  pressing  the 
two  blades  together. 

Ligature  of  the  vessel. — This  may  be  done,  by 
laying  the  artery  bare,  applying  the  ligature,  and 
dividing  the  artery  below  it.  Again,  the  two 
ligatures  may  be  applied,  and  the  vessel  divided 
between  them  ;  and  finally  the  artery  may  be  cut, 
then  seized  with  a  tenaculum  and  drawn  out,  and 
the  ligature  tied  above  the  bleeding  orifice.  The 
application  of  ligatures,  will  be  more  freely  and 
thoroughly  discussed  when  the  subject  of  "Hem- 
orrhage after  an  operation  "  is  considered. 

This  forcep  is  applicable  to  arteries  of  all  sizes, 
and  is  the  surest  of  the  methods  employed  for 
arresting  the  flow  of  blood.  Tie  the  main  artery 
first,  then  find  its  principal  branches,  and  finally 
seek  out  every  bleeding  orifice.  The  Ligature  was 
first  used  by  Ambrose  Pare  in  amputations,  but 
the  mode  of  its  application  has  been  variously 
modified  by  other  Surgeons. 

Ligatures  are  immediate  or  mediate.  To  ap- 
ply the  immediate  Ligature,  sponge  out  the  wound 
well ;  have  the  pressure  on  the  artery  slightly 
diminished,  so  as  to  permit  the  blood  to  flow ; 
seize  the  artery  either  with  a  pair  of  forceps  or 
the  tenaculum  ;  draw  it  out ;  and  having  passed 
the  thread  under  the  instrument,  make  first  a 
loose  knot,  then  direct  the  loop  over  the  artery 
and  tie  it  firmly  twice, — an  assistant  placing  his 
finger  on  the  first  knot  to  prevent  its  slipping. 
The  instrument  may  then  be  withdrawn,  and  the 
compression  removed  to  make  sure  that  the  artery 
is  completely  obliterated.     With   regard  to  small 


I  DRATIVE    MEASURES.  227 

arteries,  that  cannot  be  readily  separated  from  the 
soft  parts,  a  portion  of  the  cellular  tissue  may  be 
included  in  the  ligature  with  them. 

The  medial c  ligature  is  applied  thus.  Pass  two 
ends  of  the  ligature  through  curved  needles  ;  push 
the  first  into  the  flesh,  at  a  distance  of  half  a  line 
from  the  artery,  and  push  it  out  so  as  to  form  a 
semi-circle;  describe  a  similar  semi-circle  with  the 
other  needle,  on  the  opposite  side  of  the  artery ; 
then  tighten  the  ligature  and  the  artery  is  com. 
pressed.  This  plan  has  not  succeeded  well  on 
man. — In  the  application  of  ligatures  particular 
care  must  be  observed  not  to  include  nerves,  and 
veins. 

Torsion.  This  was  pointed  out  by  Galen  and  re- 
newed by  Amusat  with  great  success.  It  should 
be  employed  on  arteries  of  small  calibre.  Direc 
Hon*.  Draw  the  artery  out  and  isolate  it  for  half 
an  inch;  seize  it  with  a  narrow  rounebpointed/orc^p 
transversely  on  a  level  with  the  wound;  and  mash 
it  so  as  to  rupture  the  inner  coats,  while  the  proper 
torsion  forceps  are  applied  to  the  free  end  of  the 
•I,  and  the  artery  twisted  by  them  upon  its 
axis,  from  three  to  eight  times.  This  being  done, 
remove  the  upper  pair  of  forceps,  and  sink  the 
twisted  end  completely  into  the  flesh.  Fricke  simply 
isolates  the  artery  for  half  an  inch  and  then  twists 
it  completely  around  for  eight  or  nine  times. 
;_  Crushing. — The  artery  is  rubbed  and  crushed 
between  the  blades  of  the  tooth  forceps,  so  as  to 
cause  the  laceration  of  (he  two  inner  coats.  Ledran 
took  the  idea  from  observing  that  the  females  of 
'animals  boat  or  crush  the  umbilical  cord  with  their 
teeth  and  that  no  blood  flows  after  this  operation. 


228  COMPRESSION   OP   ARTERIES. 

Incision,  with  rupture  of  the  internrl  coats.— This 
is  done  by  seizing  the  artery  between  two  pairs  of 
forceps,  one  of  which  is  placed  transversely,  and 
the  other  applied  lower  down  in  the  direction  of 
the  vessel.  With  the  lower  pair,  the  two  inner 
coats  are  ruptured  and  the  fragments  pressed  up- 
wards in  the  cavity  of  the  vessel. 

Styptics. — The  various  hceraostatics  mentioned 
under  the  head  of  Capillary  Hemorrhage,  may  also 
be  employed  to  advantage  in  the  bleeding  of  small 
arteries. 

Cauterization. — The  actual  cautery  only  should 
be  used  for  arteries.  Heat  the  iron  to  whiteness, 
and  be  careful  not  to  apply  it  for  too  long  a  time,, 
lest  the  eschar  be  dragged  off  with  it.  It  is  unsafe 
for  large  arteries,  and  secondary  hemorrhage  from 
the  sloughing  of  the  eschar.  Malgaigne  how- 
ever thinks  the  "iron  should  only  be  moderately 
heated,  even  below  redness,  and  its  application 
made  at  very  short  intervals." 

The  Seton. — It  has  been  proposed  to  make  two 
openings  in  the  side  of  the  vessel  just  above  its 
mouth;  and  then  having  folded  up  the  free  end  of 
the  vessel,  to  push  it  into  the  cavity  and  to  make  it 
protrude  on  either  side  between  the  two  slits.  This 
is  a  tedious  and  difficult  process. 

Acupressure. Dr.    Simpson    has    proposed 

to  arrest  hemorrhage  by  pushing  long  metallic 
needles  through  the  integuments,  passing  them 
beneath  the  vessel  and  bringing  them  out  on 
the  opposite  side.  In  this  way  the  artery  is 
compressed  between  the  needle  and  the  super- 
imposed tissues  to  such  an  extent  as  to  arrest  its 


TREATMENT   OP  SECONDARY  HEMORRHAGE.      229 

current  completely.  The  vessel  soon  tills  with 
a  firm  clot,  the  blood  ceases  to  flow  through  it,  and 
the  hemorrhage  is  permanently  arrested.  AVhen 
the  consolidation  is  complete,  the  needles  may  be 
withdrawn  without  detriment  to  the  case.  This 
plan  is  entirely  practicable;  and  usually  ensures  a 
speedy  cicatrization,  in  as  much  as  the  needles 
produce  but  a  slight  and  transient  irritation.  Si  Iver 
needles  are  particularly  non  irritating  and  should 
be  employed,  whenever  practicable. 

Treatment  of  Secondary  1 hemorrhage.— -Nothing  can 
be  more  important  than  a  proper  comprehension 
of  the  principles  and  means  by  which  this  serious 
accident  is  to  be  met  and  managed.  The  treat- 
ment for  this  variety  of  Hemorrhage,  as  for  the 
primary,  may  be  divided  into  Preventive  and  Cura- 
tive  means. 

Preventive  means. — As  regards  the  ligature,  see 
that  it  is  of  proper  material;  apply  it  firmly;  and 
be  < ; ireful  not  to  include  portions  of  vein,  nerve, 
muscle,  &c. 

A  s  regards  the  vessel,  seek  for  a  healthy  portion  • 
avoid  large  branches  ;  be  particular  not  to  wound 
the  vessel ;  and,  in  wounds,  never  neglect  to  ap- 
ply the  ligature  to  both  of  the  divided  ends  of  the 
artery. 

As  regards  the  blood,  ascertain  its  condition,  and 
seek  to  improve  it  both  by  removing  the  cause  of  its 
impairment ;  ana  by  supplying  the  deficient  ele- 
ments. Iron,  stimulants,  good  food,  and  confidence 
iii  the  Surgeons,  are  the  surest  remedies. 

regards  the  system  at  large,  rostrain  the  force 
of  the  circulation  by  means  of  Digitalis,  and  Vera 
10 


230  CURATIVE   MEASURES. 

trum  Veride,  and  if  necessary  treat  existing  com- 
plications. Bring  the  system  to  its  normal  status, 
or  as  near  it  as  possible. 

Curative  measures. — By  this  term  is  meant  those 
agencies  which  may  be  employed  for  the  arrest  of 
Hemorrhage  after  its  developement.  Should  bleed- 
ing occur  from  a  stump  after  amputation,  the  follow- 
ing course  should  be  persued :  If  the  Hemorrhage 
be  developed  only  a  few  days  after  the  operation, 
bandage,  elevate,  and  apply  cold  water ;  then,  if 
this  prove  unsuccessful,  open  the  flaps,  try  cold 
water,  styptics,  &c,  and  bring  the  parts  firmly 
together;  and,  if  the  bleeding  still  continue,  open 
the  wound  again,  search  for  the  bleeding  vessel, 
and  tie  it. 

If  the  bleeding  occur  at  a  later  period,  make  an 
effort  to  arrest  it  by  compression  with  the  horse 
shoe  tourniquet,  and  if  this  fail,  ligate  the  artery, 
if  possible,  in  the  wound.  When  the  artery  cannot 
be  tied  in  that  locality,  it  must  be  ligated  at  the 
most  convenient  point  above. 

Should  Hemorrhage  present,  itself  after  a  ligature 
has  been  applied,  the  Surgeon  may  adopt  the  follow- 
ing course :  If  the  artery  belong  to  the  trunk  and 
the  application  of  a  ligature  at  a  nearer  point  to  the 
heart  be  impracticable,  an  attempt  should  be  made 
to  arrest  the  flow^by  means  of  plugs  saturated  in 
certain  styptic  preparations,  as  the  persulphate  or 
chloride  of  Iron — the  tincture  of  Benzoin,  while 
an  effort  is  made  to  restrain  the  force  of  the  circu^ 
lation. 

If  the  artery  be  situated  in  some  one  of  the  ex* 
tremities,  elevation,  plugging,  and  the  graduated 


YTIVE    MEASURES.  231 

compress  should  be  employed.  When  these  means 
fail,  and  the  artery  is  on  the  upper  extremity,  the 
wound  should  be  reopened  and  the  vesse]  tied  both 
above  and  below  the  bleeding  point  it'itbe  possible  • 
but  if  not,  it  should  be  ligated  higher  up.  Should 
the  hemorrhage  slid  continue,  amputate  the  limb. 
Secondary  hemorrhage,  occurring  in  the  lower  ex- 
tremity, is  more  difficult  to  control.  Tie  the  arte- 
ry in  the  wound,  both  above  and  below  the  bleeding 
point;  and,  when  this  fails, proceed  at  once  to  am. 
putate.  Experience  has  demonstrated  the  imprac- 
ticability of  applying  the  ligature  higher  up, 
as  gangrene  invariably  follows  such  a  procedure. 
Bleeding  in  connexion  with  a  wound.  All 
injuries  to  arteries  threaten  to  produce  secondary 
hemorrhage,  and  this  danger  increases  with  the 
size  of  the  vessel.  Prevention  is  therefore  the  rule 
of  modern  Surgery,  and  it  is  possible  to  accompl  ish 
this  in  a  majority  of  cases,  b}<  the  proper  appli- 
cation of  the  ligature,  in  the  premises.  Make  it 
an  invariable  rule  then,  to  ligate  the  artery  as  soon 
as  the  injury  has  been  received,  by  opening  the 
wound  and  tying  both  extremities.  If  the  divided 
artery  be  a  small  one,  do  not  disturb  it,  after  it 
ceases  to  bleed  spontaneously ;  but,  on  the  other 
hand,  if  the  s<  Vi  red  trunk  be  of  large  cedibre, — as  the 
femoral,  the  tibial,  or  tin'  brachial — and  no  doubt 
exists  as  to  the  nature  of  the  injury,  apply  the  Uqa- 
tures,  even  if  hi  morrhage  has  ceascdof  its  own  accord 
This  rule  should  he  particularly  observed  upon  the 
battle  field,  as,  in  the  transportation  necessarv  to 
convey  the  soldier   to    the   hospital,  there    is    the 


232  CURATIVE    MEASURES. 

greatest  possible  danger  of  a  reopening  of  the  vessel, 
and  the  consequent  destruction  of  his  life.  It  is 
impossible  to  construct  ambulances  in  such  a  man- 
ner as  to  prevent  a  great  amount  of  jostling,  while 
conveying  the  wounded  over  ordinary  roads,  espe- 
cially if  the  country  be  hilly,  or  trains  of  artillery 
have  passed  over  them,  in  advance.  This  fact 
should  be  remembered  by  the  Surgeon  to  whose 
care  the  severed  artery  first  falls  upon  ^the  field  • 
and,  without  regard  to  the  mere  dictum  of  recog- 
nized authorities,  he  should  follow  the  guidance  of 
common  sense,  and  employ  the  only  sure  means 
for  the  prevention  of  a  fatal  accident.  When  the 
wound  is  recieved  under  circumstances  which  per- 
mit the  employment  of  other  means  of  a  milder  and 
less  heroic  character  this  rule  is  not  so  imperative, 
and  position,  repose,  quiet,  compresses,  and  other 
prophylactics,  may  be  resorted  to  in  order  to  pre- 
vent the  return  of  hemorrhage. 

Bear  in  mind,  that  as  troublesome,  difficult,  and 
dangerous  as  the  operation  for  the  ligation  ot  an 
artery  may  be,  it  is  a  far  less  serious  thing  than 
hemorrhage  from  a  large  arterial  trunk,  such  as 
the  femoral,  the  popliteal  ©r  the  brachial,  and 
that,  where  there  is  a  reasonable  probability  of  ex- 
posure to  such  disturbing  influences  as  tend  to  re- 
produce the  hemorrhage,  the  ligature  should  be 
promptly  and  properly  applied,  in  advance. 

If  these  precautions  are  negiectud,  and  hemor- 
rhage reappears  after  having  been  controlled,  it 
is  usually  from  the  lower  ■portion  of  the  artery.  In 
such  cases  the  blood  does  not  come  in  jets,  but 
wells  out  in  a  continuous  stream,  and  is  of  a  dark- 


CI  NATIVE    MEASURES.  233 

cr  color  than  usual.  The  course  to  be  pursued  is 
as  follows  :  Bandage  the  limb  from  one  extremity 
to  the  other  so  as  make  careful  and  regular  pres- 
sure throughout  its  whole  extent;  both  above  and 
A.  low  the  wound,  along  the  track  of  the  main  ar- 
tery, apply  a  compress  saturated  with  the  persul- 
phate of  iron,  or  sonic  other  styptic  ;  elevate  the 
limb  ;  apply  an  ice  bladder,  or  a  continuous  stream 
of  cold  water  immediately  over  the  wound  ;  give 
an  opiate,  and  command  absolute  quiet.  Should 
there  be  much  force  in  the  heart's  pulsations,  the 
circulation  may  be  controlled  by  the  administra 
tion  of  digitalis,  veratrum,  viride,  &c. 

[fa  second  hemorrhage  make  its  appearance,  al- 
ter the  employment  of  the  means  referred  to  above, 
the  artery  should  be  immediately  secured,  in  the 
wound,  if  possible,  although  it  be  in  a  condition 
of  profuse  suppuration. 

If  the  ligature  cannot  be  applied  at  this  point, 
tie  the  artery  higher  up,  according  to  the  rules  and 
principles  which  will  be  given  in  detail,  under  an- 
other head. 

When  all  of  these  measures  have  been  tried  in 
vain,  and  the  bleeding  again  makes  its  appearance, 
and  resists  ordinary  treatment,  amputate  the  limb 
as  a  last  resort. 

Should  secondary  hemorrhage  take  place  from 
the  veins,  in  consequence  of  an  opening  of  their 
coats  by  ulceration  or  suppuration,  graduated  com- 
pression from  the  extremity  upwards,  must  be 
employed,  and  ligation  resorted  to  only  in  the 
most  extreme  contingency. 

Aatthis  is  one  of  the  most  fearful  and  fatal  ac- 


234  CURATIVE   MEASURES. 

cidents  to  which  the  human  frame  is  subject,  after 
the  performance  of  operations  on  the  receipt  of  in- 
juries, the  principles  upon  which  its  treatment  is 
based,  should  be  thoroughly  understood  by  the  mil- 
itary Surgeon.  He  must  act  not  only  promptly  but 
correctly,  or  else  lose  his  patient,  and  feel  himself 
responsible  for  the  fatal  issue.  By  following  the 
rules  established  for  his  guidance  in  the  preceding 
pages,  he  will  not  only  have  the  satisfaction  of 
saving  life  in  many  instances,  but  also  of  knowing 
that  in  any  event  he  has  done  his  whole  duty. 
There  surely  can  be  no  more  comforting  reflection 
than  this,  to  the  conscientious  Surgeon,  amid  the 
cares,  responsibilities  and  discomforts  of  his  ar- 
derous  life. 

Although  it  cannot  be  questioned  that  a  ligature 
applied  to  the  ends  of  a  divided  artery  is  the  sur- 
est method  of  arresting  the  bleeding,  it  is  fre- 
quently a  matter  of  the  greatest  difficulty  to  find 
them,  or  even  to  determine  which  artery  is  bleed- 
ing. Again  when  fracture  complicates  the  wound, 
great  injury  may  be  done  by  exposing  it  to  the  ac- 
tion of  atmospheric  air.  It  must,  therefore,  be 
borne  in  mind,  that  though,  ligature  of  both  the 
proximal  and  distal  end  is  the  rule  which  should 
be  followed  as  a  general  thing,  under  these  cir 
cumstances,  the  main  trunk  of  the  vessel  should 
be  tied  above,  according  to  the  plan  proposed 
by  Anel,  and  insisted  upon  by^  Dupuytren  and 
others. 


LIGATION  OF   ARTERIES.  235 


CHAPTERVI. 


LIGATION  OF  ARTERIES." 

Ligation  of  Arteries. — Arteries  may  bcligated 
at  different  points,  thus  : 

1.  Above  the  point  of  division'or  disease. 

2.  Both  above  and  below  the  point  of  division 
or  disease. 

3.  Below  the  point  of  division  or  disease,  exclu- 
sively. 

The  circumstances  under  which  the  ligation 
the  artery  above  the  2>oint  of  division  or  disease  is 
demanded,  are  the  following: 

1.  After  amputations  for  the  purpose  of  arrest- 
ing the  flow  of  blood. 

2.  In  wounds  of  small  arteries  when  the  hemor 
rhage  cannot  be  otherwise  restrained. 

3.  In  local  hypertrophies  for  the  purpose  of  ar- 
resting the  nutritive  process  by  withholding  the 
pabulum  supplied  by  the  blood. 

4.  In  connexion  with  malignant  tumours  and 
for  the  purpose  of  restraining  their  develop- 
ment. X 

5.  In   aneurysmal  tumours,   according    to  'the 


236  LIGATION  OP  ARTERIES. 

teachings  of  Hunter,  taking  care  to  expose  the  ar- 
tery at  some  distance  from  the  seat  of  disease. 

6.  In  vounds  of  large  arteries  when  it  is  impossi- 
ble to  ligate  bojth  the  proximal  and  distal  end. 

7.  In  hemorrhage  from  an  artery  in  simple  frac- 
ture, performing  Anil's  operation  according  to  the 
views  of  Dupuytren. 

8.  In  secondary  hemorrhage  of  an  uncontrollable 
character  from  stumps,  &c. 

9.  In  violent  inflammations  of  articular  surfaces, 
when  neither  resections  nor  amputations  are  admis- 
sible. 

The  circumstances  which  demands  the  ligation  of 
the  artery,  both  above  and  below  the  point  of  division 
or  disease  are  the  following : 

1.  In  secondary  resections  where  the  collateral 
circulation  has  been  developed,  and  the  hemorrhage 
is  excessive, — the  operation  oeing  tedious  and  pro- 
longed. 

2.  In  traumatic  aneurisms,  particularly  those  of 
the  artero-  venous  variety,  the  ligature  should  be 
thus  applied.  The  older  Surgeons  treated  all  aneur- 
isms in  this  method,  but  it  is  now  limited  to  those 
of  traumatic  origin. 

8.  In  wounds  generally  when  an  artery  of  large 
size  is  divided,  as  a  means  of  preventing  secon- 
dary hemorrhage. 

4.  In  secondary  hemorrhage  when  from  the  dark 
hue' of  the  blood,  and  the  continuity  of  the  stream, 
it  is  plain  that  the  blood  issues  from  the  distal  end 
of  the  artery.  The  application  of  the  ligatures 
both  to  the  proximal  and  distal  ends  of  the  artery, 
under  these  circumstances  will  be  readily  appreci- 


LIGATION   OF   ARTEK1I-.  237 

ated  when  it  is  remembered  that  the  latter  does  not 
close  as  docs  the  former,  and  that,  as  a  natural  con. 
sequence,  so  soon  as  the    collateral   circulation    is 
developed,  the  blood  comes  welling  up  from    the 
patulous  oriiiee  in  obedience  to  the   physical   law 
whirh  constrains  a  fluid  to  seek  its  own  level  under 
all  circumstances.     The  causes  which  prevent  the 
closure  of  of  the  distal  end,  depend  for  their  oper- 
ation upon  the  division  of  the  nerves  distributed  to 
that  portion  of  the  vessel,  and  the  retention  in  if  y 
immediately  subsequent  to  the  operation,  of  too 
small  a  quantity  of  blood  to  ensure  the  formation 
of  a  clot  sufficiently  large  and  firm  to  block  up  the 
vessel.     This  method  of  guarding  against  seconda- 
ry hemorrhage,  and   of  restraining  it  when  devel- 
oped,  has   become  one  of  the  axioms  of  modern 
surgery,  and  should  be  incorporated  into  the   pro- 
mal  creed  of  every  medical  man  as  a  cardinal 
principle.     The  neglect  of  this  most  simple  but  sig- 
nificant precept  may  induce  fatal  results,  for  which 
the  Surgeon  alone  should  be  responsible,  whatever 
of  mortification   to  him  or  disgrace  to  the  profes- 
sion, is  incurred  thereby.     As  before  remarked,  it 
is  not  always  possible  to  ascertain  from  what  arte- 
ry the  blood  conies,  or  to  find  the  severed  ends  of 
the  bleeding  vessel  :  but  the  operation  should  not 
be  abandoned  for  any  other,  until  a  diligent  search 
has  been  instituted  and  an  intelligent  effort   made 
to  fulfill  the  indication  of  the  case,  in  the   manner 
referred  to  above. 

The  blood  from  the  distal  portion  of  the  divided 
artery  may  be  recognized  in  the   lower   extremi- 
ties by  the  darkness  of  its  hue,  but  in  the  upper 
10b 


238  LIGATION   OF   ARTERIES. 

extremities  both  ends  bleed  scarlet  blood  because 
of  the  free  anastamoses  of  the  vessels. 

It  is  not  so  important  to  secure  both  ends  of  the 
smaller  arteries,  as  they  can  be  more  readily  ob- 
literated, if  necessaiy,  or  controlled  in  any  event. 

The  circumstances  under  which  the  artery  is  li- 
gated  below  the  point  of  division  or  disease  exclu- 
sively are  as  follows  : 

1.  In  anuerisms  of  large  vessels  when  the  Ilun- 
terian  operation  has'  failed  or  is  impossible. 

2.  In  aneurisms  when  the  coats  of  the  artery  are 
diseased  in  consequence  of  calcarious  or  arthero- 
rnatous  deposits. 

3.  In  wounds  when  the  hemorrhage  is  of  a  dark 
character  and  comes  in  a  continuous  stream,  and 
the  upper  portion  of  the  divided  artery  lias  re- 
tracted beyond  the  reach  of  the  Surgeon,  or  is  in 
such  close  proximity  with  important  organs  as 
precludes  its  seizure  without  serious  injury  to 
them . 

Brasdor  proposed  to  cure  aneurismal  tumours 
by  ligating  the  artery  only  on  the  distal  side,  ex- 
pecting thereby  to  retard  and  diminish  the  current 
passing  through  the  tumours  to  such  an  extent  as  to 
ensure  the  consolidation  of  its  contents.  Experi- 
ence has  shown  that  the  Hunterian  method  is  far 
preferable,  and  that  the  procedure  of  Brasdor  is  a 
senseless  substitution  save  in  those  cases  where 
from  the  peculiar  surroundings  of  the  vessel  the 
former  cannot  be  performed.  "Wardrop  supposed 
that  by  tying  the  artery  on  the  distal  side,  but  be- 
yond a  point  of  bifercation,  that  the  conditions 
most  essential  to  solidification  of  the  aneurism 


-LIGATION   OF   ARTERIES.  239 

would  bo  secured.  The  iucorrectness  of  his  views 
in  this  regard  is  demonstrated  by  the  universal 
abandonment  of  his  operation. 

Structure  of  Arteries. — It  is  important  to  under- 
stand the  anatomical  structure  of  arteries  before 
entering  upon  the  consideration  of  the  general 
rules  for  the  application  of  ligatures. 

Arteries  are  tubular  vessels  of  cylindrical  form 
dense  in  structure,  and  composed  of  three  coats,  the 
internal,  the  middle  and  the  external. 

The  internal  coat  is  clastic,  and  composed  of  two 
layers,  the  innermost  one  being  only  a  layer  of 
epithelial  cells,  resting  upon  an  elastic,  but  ex- 
tremely thin,  brittle,  transparent  and  colorless 
membrane. 

The  middle  coat  is  composed  both  of  muscular 
and  elastic  fibres,  being  highly  elastic,  and  of  a 
reddish  yellow  color.  These  muscular  and  elastic 
fibres  are  arranged  in  layers,  encircling  the  vessel, 
and  therefore,  admitting  of  an  easy  division  of 
this  coat,  under  .the  presure  of  a  ligature  applied 
in  the  same  direction. 

The  external  or  elastic  coat  consists  of  condens- 
ed areolar  and  elastic  tissue.  In  large  arteries  the 
elastic  tissue  forms  a  distinct  layer,  the  fibres  of 
which  run  longitudinally,  while  another  layer  of 
condensed  areolar  invests  the  whole, — its  fibres 
being  disposed  more  or  less  obliquely  or  diagonal* 
ly  around  the  vessel. 

The  arteries  are  included  in  a  thin  areolar 
investment  known  as  the  sJieath,  and  are  sup- 
plied with  blood  vessels  and  nerves  like  other  or- 
gans £of  the  body;   while  they  are  accompanied 


240  ACTION   OF   LIGATURES. 

by  satellite  veins,  called  vence  comit'es.  The  nutrient 
vessels  arise  from  the  main  artery,  from  some  of 
its  branches,  or  from  a  neighboring  vessel,  and 
are  distributed  to  the  external  and  middle  coats,, 
and  possibly  to  the  internal,  also.  Minute  veins 
serve  to  return  the  blood  from  the  vessel  into  the 
venae  comites.  The  veins  are  derived  principally 
from  the  sympathetic,  and  partly  from  the  cerebro 
spinal  system, — forming  intricate  plexuses  upon 
the  surface  of  the  larger  trunks,  while  the  small- 
er branches  are  accompanied  .by  single   filam 

These  vessels  are  named  arteries  from  two  Greek 
words  signifying  "to  contain  air,"  from  the  an-, 
cient  popular  but  most  mistaken  ideas  respecting 
their  functions. 

llie  action  of   Ligature*. — "When   a  ligature  is; 
tightly  applied  to  an  artery  of  considerable  size, \ 
certain    pathological   phenomena    are   developed^ 
worthy  the  faithful  study  of  the  Surgeon.     Thesoj 
effects  occur  in  the  following  order  :   An  immedi- 
ate division  of  the  internal  and  middle  coats — thai 
external  remaining   in  tact;— these    coats  retraci 
and  contract  forming  a  cul-de-sac,  at  the  bottom  of 
which,  there  is  first  deposited  a  small   nodule  o^j 
lymph  of  i  yellowish  or  buff  color.;  this  coagulun 
assume.^  a  conical  shape,  its  base  being  downward^ 
and  is  c     lposecl  of  exudation    matter    and  fibril 
closely  ;    herent  to  the  lower   end  of  the  artery, 
while  it     ipex  is  pointed  upwards,  floats  loose  iij 
the  vest  2]    and  is  composed  of  fibrin,  of  a  darl 
purple  <     maroon  color ;  about  the  tenth  day  tl 
plastic  \j  aph,  thrown  out  in  consequence  of  an  ii 
flammat.  ,>n  from  the  divided  coats,  binds  thei 


iOTION   OF    LIGATURES.  241 

firmly  to  the  inclosed  plug,  the  darker  portions 
of  which  begin  to  disappear  ;  the  vessel  contracts 
still  more,  and  the  absorption  of  coloring  matter 
continues,  until  the  base  of  the  plug  becomes  in- 
corporated with  the  contiguous  arterial  coats  and 
is  finally  transformed  into  nbro — cellular  tissue. 
In  the  external  coat  a  certain  amount  of  inflamma- 
tion is  induced  by  the  pressure  of  the  ligature, 
and  plastic  lymph  is  exuded  between  the  vessel 
and  its  sheaths  which  finally  organizes  and  mate- 
rially strengthens  the  artery  immediately  contigu- 
ous to  the  noose  as  well  as  over  it.  The  ligature 
finally  ulcerates  through  the  vessel,  and  its  place 
is  still  farther  supplied  by  deposits  of  plastic  mat- 
ter upon  the  external  coat  of  the  vessel. 

It  will  be  seen  therefore  that  the  simple  retrac- 
tion and  contraction  of  the  severed  coats,  together 
with  the  formation  of  a  coagulum,  are  not  sufficient 
to  secure  the  occlusion  of  the  vessel,  but  that  the 
inflammatory  process,  accompanied  by  effusion  of 
plastic  lymph,  must  develop  itself  in  order  to  effect 
the  desired  result.  The  delicacy  of  the  arterial 
coat  ensures  the  induction  of  this  inflammation 
when  the  ligature  is  applied  under  ordinary  cir- 
cumstances,— a  provision  of  immense  importance 
to  the  Surgeon,  and  seemingly  designed  with  espe- 
cial reference  to  the  success  of  the  art.| 

The  instruments  and  appliances  required  lor  this 
operation  are  few   and   of  simple  construction. — 


%  There  mi  luch  or  too  little  inflammation, — the  one  some" 

tinTcs  resulting  in  the  breaking  down  of  the  coagulum  by  suppuri 
the  other  causing  the  exudation  of  so  little  ubrine  as  to  preclude  the 
ormation  of  I  ly  firm  clot  to  ensure  obliteration. 


242  OBJECTS    IN   VIEW. 

Thus,  the  Surgeon  should  always  be  provided  with 
a  bistoury,  a  grooved  director,  forceps,  aneurismal 
needles,  blunt  hook,  tenacuke,  ligatures,  suture 
needles,  adhesive  straps,  chloroform,  styptics,  cold 
water  and  brandy. 

2  he  objects  to  be  held  in  view  in  the  performance  of 
this  operation  are  three  in  number,  viz  : 

1.  To  expose  the  sheath  of  the  vessel. 

2.  To  isolate  the  artery. 

3.  To  place  the  ligature  around  the  artery. 
Uncovering  the  Artery. — The  general   rules   in 

this  regard,  may  be  summed  up  thus : 

1.  Make  sure  of  the  position  of  the  artery  by  un- 
derstanding the  anatomy  of  the  part,  causing  the 
muscles  to  contract,  feeling  the  pulsations,  and 
"  make  assurance  doubly  sure,"  by  marking  out, 
upon  the  limb,  the  exact  course  of  the  vessel. 

2.  Make  the  skin  tense  without  altering  its  rela- 
tion to  the  artery  ;  and  if  the  vessel  be  superficial, 
cut  directly  through  the  skin  and  parallel  with  it; 
but  if  it  be  deep  divide  the  skin  obliquely. 

3.  If  the  artery  lies  directly  under  the  superficial 
fascia,  or  aponeurosis,  these  should  be  opened  at 
the  side  of  the  vessel  to  avoid  puncturing  it ;  but 
if  the  artery  be  deep  they  should  be  opened  direct- 
ly above  it.  Should  the  artery  not  be  seen  after 
these  incisions,  make  the  muscles  contract,  and 
separate  them  at  their  insterstices,  by  means  of  the 
director  or  the  handle  of  the  knife.  When  the 
deep  aponeurosis  is  exposed  it  should  be  divided 
according  to  the  directions  given  for  the  superfi- 
cial. 

4.  The  artery  may  be  recognized  by  its-  pulsa- 


ISOLATION   OF   THE   ARTERY.  243 

lions,  by  its  being  thicker  than  the  veins,  and  by  its 
dull  white  color. 

5.  However  superficial  the  artery,  two  incisions 
are  alwaryi  sary  to  uncover  it — the  s-kin   and 

the  aponeurosis  must  always  he  divided,  and  by 
separate  cuts.  The  Surgeon  should  never  cut 
blindly,  hut  always  "with  a  definite  object  in  view, 
and  with  a  lull  knowledge  of  what  he  is  doing. — 
He  should  have  certain  anatomical  land  marks  to 
guide  him  to  the  attainment  of  his  object,  and 
should  content  himself  with  quietly  tin  ding  each 
in  its  turn  until  the  goal  is  reached,  without  seek- 
ing to  attain  it  at  a  bound,  or  by  an  extemporized 
•'shortcut." 

The  Isolation  of  the  Artery. — The  rules  for  the 
guidance  of  the  Surgeon  in  separating  the  artery 
from  its  surroundings  are  as  follows: 

1.  Hold  aside  the  lips  of  the  wound,  and  remove 
all  pressure  upon  the  artery  so  as  to  distinguish  its 
pulsations,  and  when  the  sheath  is  fairly  exposed, 
and  opened,  pass  in  the  grooved  director,  and  en- 
large the  opening  either  by  cutting  or  tearing  the 
membrane.  Then,  separate  the  artery  from  its  ac- 
companying veins  and  nerves,  and  pass  the 
grooved  director  b<  ueath,  and  thus  isolate  the  ves- 
sel. 

2.  If  the  artery  be  small,  or   yellow — indicating 

its  sheath  should  not  be  opened.     If  it  be 
large,  the   sheath,    separate   it  from  "Venae 

comites"  and  "  satellite  nerve;"  and  adily 

with  the  finger  and  thui  to  pa      the   director 

under  it. 
;3.  If  important  ■  taken  up  with  the  arte- 


244  APPLYING  THE  LIGATURE 

ry  by  the  director,  use  another  to  ensure  its  more 
complete  isolation. 

4.  Be  sure  that  yon  have  tied  the  artery.  Some 
have  tied  important  nerves  instead  of  the  vessel, — 
with  the  most  destructive  consequences  to  the  pa- 
tients, and  to  their  own  reputations.  Take  pains 
therefore,  to  feel  the  pulsations  of  the  vessels  before 
ligating,  and  to  ascertain  that  the  current  of  blood 
has  been  arrested  b}'  the  operation,  by  examining 
the  artery  both  above  and  below  the  ligature. : — 
With  regard  to  the  veins,  their  colour  will  prevent 
mistakes 

Applying  the  Ligature. — The  rules  for  applying 
the  ligature  are  as  follows  , 

1.  The  ligature  must  compress  the  artery  per. 
pendicularly  ;  if  placed  obliquely,  it  will  slip  and 
not  sufficiently  compress  the  vessel. 

2.  The  ligature  should  neither  be  too  small,  nor 
too  loose,  but  should  vary  according  fo  the  vessel 
ligated,  having  a  certain  relation  to  "the  size  of  the 
artery.  Thus,  the  femoral  should  be  tied  with  a 
larger  thread  than  the  facial,  and  •  so  on  for  the 
rest. 

3.  Do  not  tie  an  artery  immediately  below  a 
branch 

4.  Disturb  the  ligature,  after  it  has  been  adjust- 
ed, as  little  as  possible. 

When  an  artery  is  diseased  or  brittle,  the  ligature 
should  be  large,  and  tied  loosely. 

For  the  other  facts  in  regard  to  the  application 
of  ligatures,  the  reader  is  referred  to  the  previous 
chapter  on  hemorrhage. 

Treatment. — After  the  operation  has  been  per- 
formed the  limb  should  be  placed  in  such  a  posi- 


TREATMENT.        '  245 

tion  as  will  permit  the  blood  to  flow  readily  from 
it,  while  the  muscles  are  relaxed  and  the  lips  of 
the  wound  are  neither  patulous  nor  puckered. 
The  wound  should  be  closed  with  adhesive  straps ; 
the  ligatures  brought  out  of  its  upper  portion;  a 
Light  roller  bandage  applied;  and  the  cold  water 
treatment  instituted.  Provision  should  also  be 
made  for  preserving  the  vital  warmth  of  the  Limb, 
by  wrapping  it  in  flannel,  laying  it  in  a  bed  ol 
soft  wool  or  cotton,  using  friction  and  employing 
artificial  heat  if  necessary.  The  ligatures  should 
not  be  touched  for  eight  or  ten  days,  if  the  artery 
be  small,  and  for  two  weeks  or  more  if  it  be  of  large 
calibre.  If  symptoms  of  plethora  appear  from  the 
mass  of  blood  being  confined  within  more  circum- 
scribed limits,  blood  letting  and  the  usual  anti- 
phlogistic treatment  should  be  resorted  to  without 
delay.  Should  gangrene  result  from  the  ligation 
of  the  artery,  amputation  offers  strong  hope  for 
the  patient,  and  it  should  be  employed  without 
hesitation  or  delay.  This  accident  is  particularly 
likely  to  appear  in  connexion  with  extensive  gun 
shot  wounds,  or  when  owing  to  the  ignorance  or 
carelessness  of  the  operator,  the  large  conducting 
vein  from  the  limb  is  injured,  or  an  aueurismal 
communication  is  formed  between  the  artery  and 
its  accompanying  vein.  Should  hemorrhage  oc- 
cur as  the  ligature  separates,  compression  may  be 
tried,  and  [f  this  fail,  another  operation  resorted 
to  as  the  surest  means  of  arresting  the  flow. 

Ligation  of  Particular  Arteries. — Under  this 
head  will  be  considered  the  rules  for  the  ligation 


246  ARTERIA   INNOMlNATA. 

of  the  arteries  of  the  trunk,  and  of  the  superior 
and  inferior  extremities. 

Arteries  of  the  Trunk — UieArteria  Innominate; 
This  artery  is  the  first  large  trunk  given  off  from 
the  arch  of  the  aorta,  and  ascends  obliquely  on 
the  right  side,  to  a  point  opposite  the  articulation 
of  the  clavicle  with  the  sternum,  where  it  termi- 
dates  by  dividing  into  the  subclavian  and  common 
carotid.  It  is  about  one  inch  and  a  half  in  length, 
in  the  adult,  and  is  in  front  of  the  trachea. 

PLAN    OF   RELATIONS. 

In  front. — The-sternuni,  sterno-hyoid,  and  sternothyroid 
muscles,  remains  of  the  thymus  gland,  left  innomenata  and 
inferior  thyroid  veins. 

Right  side.— Right  Vena  innomenata,  right  pneumogastric 
nerve  and  pleura. 

Left  side. — Remains  of  the  thymus  gland,  and  left  carotid. 

Behind. — The  trachea. 

Operation. — Directions. — Place  the  patient  in  a 
recumbent  position,  with  the  neck  slightly  flexed 
and  supported  with  a  pillow, — the  face  being  turn- 
ed in  an  opposite  direction,  so  as  to  relax  the  ster- 
no-cleido-mastoid  muscle.  Standing  upon  the  right 
side,  make  a  transverse  incision,  three  inches  long, 
commencing  at  the  median  line,  of  the  neck  and 
extending  outwards  parallel  with  the  clavicle  but 
half  an  inch  above  its  upper  border ; — then  make 
another  incision  of  the  same  length  along  the  in- 
ner border  of  the  sterno-cleido-mastoid,  terminating 
at  the  commencement  of  the  first ;  open  the  pla- 
tysmar  muscle  and  superficial  fascia  carefully,  so 
as  to  expose  the  sternal  portion  of  the  sterno-clei- 
do-mastoid ;  divide  this  muscle  upon  the  grooved 
director  ;  separate  the  clavicular  origin  of  the  mus- 
cle upon  the  inner  side  of  two  thirds  of  its  length 


AIITE1UA  INNOMINATA.  247 

and  reverse  it  upwards  and  o\d\oards  ;  next  divide 
the  sternohyoid  and  thyroid  muscles,  cautiously 
upon  the  grooved  director ;  open  the  cellular  tissue 
lying  above  the  vessel  with  the  finger  or  director 
avoiding  the  right  internal  ingular  vein,  which  is 
only  a  quarter  of  an  inch  on  its  outer  side,  and 
the  inferior  thyroid  veins  which  cover  it  in  front 
and  are  to  be  drawn  oil'  on  one  side; — find  the 
common  carotid  first,  and  trace  it  down  with  the 
finger  until  the  innominata  is  discovered  ;  separate 
the  vessel  carefully  from  the  vena  innominata  on  its 
outer  side,  and  press  it  off  from  the  laryngeal  ; 
and  then  pass  the  ligature  under  it  by  means  of  a 
curved  aneurismal  needle  from  without  inwards. 
The  longitudinal  incision  may  be  made  first,  and 
perhaps  it  is  more  convenient  to  do  so,  as  the  skin 
becomes  relaxed  after  the  transverse  one  is  made. 
The  parts  should  be  brought  together  and  cold 
water  dressings  applied. 

The  propriety  of  attempting  this  operation  un- 
der any  circumstances  is  very  doubtful  though  the 
facts  o(  thr  accidental  obliteration  of  this  artery 
demonstrates  the  possibility  of  success. 

Ligation  of  th<  Common  I  Artery 

PLAN  OF  RELATIONS. 

/,-  Front. — Integument,  fascia,  platysma,  sterno-mastoid, 
■terno-tbyroid,   i  [en    noni   nerve,   *t<-nei_ 

•1  artery,  .superior  and  mid  :  thyroid  veiny,  and  anterior 
ugular. 

f. — Internal     jugular    vein    and    pneumo-gastrie 
nerve. 

.—Trachea,    thyroid    gland,    recurrent  laryngeal 
nerve,  inferior  thyroid  artery,  larynx  and  pharynx. 

stic  nerve,  rectus  anticus 
muscle,  interior  thyroid  artery  and  recurrent  laryngeal 
nerve. 


248  COMMON  CAROTID   ARTERY. 

The  common,  carotid.arteries  extend  from  a  point 
opposite  the  articulation  of  the  clavicle  and  sternum 
to  a  point  on  a  level  with  the  superior  margin  of 
the  thyroid  cartilage,  where,  they  divide  into  the 
external  and  internal  carotids.  Both  arteries  in- 
cline backwards  as  they  ascend,  while  the  right  is 
shorter  than  the  left,  and  somewhat  more  superior, 
in  consequence  of  its  coming  off  from  the  innomina- 
ta.  Each  artery  is  invested  in  a  sheath  which 
contains  also,  the  par  vagum  nerve  and  the  internal 
jugular  vein — the  artery  being  on  the  inner  side, 
next  to  the  trachea — the  vein  on  the  outer  side,  and 
the  nerve  bchueen  the  two  but  a  little  posterior  to 
them. 

The  place  of  election  is  immediately  below  the 
bifurcation  of  the  vessel,  opposite  the  thyroid  car- 
tilage, and  above  the  omo-hyoid  muscle. 

The  place  of  necessity  is  anywhere  below  the 
omo-hyoid  and  in  the  interior  triangle  of  the 
neck. 

Directions  for  the  operation  at  the  place  of  elec- 
tion. Place  the  patient  in  a  recumbent  position, 
with  his  face  turned  to  the  opposite  side,  well  sup- 
ported by  an  assistant,  and  his  chin  carried  back 
so  as  to  extend  the  integuments  in  front  of  th 
neck.  Make  an  incision  on  the  anterior  edge  o 
the  sterno-cleido-mastoicl,  beginning  an  inch  below; 
the  angle  of  the  jaw  and  extending  half-way  down 
the  neck:  raise  and  divide,  on  the  grooved  direc- 
tor, the  platysma  muscle  and  superficial  fascia,, 
avoiding  the  anterior  jugular  vein  and  the  superfi]| 
cial  nerves ;  divide,  in  the  same  manner,  the  dee 
layer  of  fascia,  connecting  the  edge  of  the  stern( 


:; 


COMMON  CAROTID   ARTERY.  249 

clcido-mastoid   to   the  sterno-thyroid   and    hyoid 
muscles  ;  lay  down  the  scalpel,  lower  the  chin  to  its 
usual  position  so  as  to  relax  the  muscles,  and  hold 
the  margins  of  the  wound  asunder  with  blunt  hooks 
or  the  lingers  of  an  assistant;  then,  with  the  point 
of  the  director,  the   handle  of  the  knife,  or   the 
linger,  break  up  the  cellular  tissue  so  as  to  expose 
the  sheath  of  the  vessel,  on  which  is  the  descendens 
noni  nerve;  raise  the  sheath  carefully  with  the  for" 
and  open  its  inner  side,  and  enlarge  the   ori- 
fice on  a  director  so  as  to  expose   the  vessel;  hold 
the  internal  jugular  vein   slightly  downwards  and 
outwards,  isolate  the  artery,  and  pass   the  ligature 
under  it,  by  means  of  an  aneurismal  needle,  from 
without   inwards.      If    the   internal  jugulor  vein 
should  by  anj  accident  be  severed  in  the  operation 
two  pieces  through  its  edges   and   across   the 
orifice,   and   immediately   apply   a  ligature  both 
above  and  below  the  bleeding   point.     Bring   the 
wound  together  ami  dress  according   to   the  usual 
rule 
Directions  for  the  operation  at  the  point  of  ne- 
the   omo-hyoid  muscle. — Make,  an 
incision   three   inches  in  length  along  the  inner 
:in  of  the  stern o-cleido-mastoid  terminating 
»p    oi    the   sternum;   an  inch  from    this 
point,   make  another    incision    parallel    with    the 
elavi.  beyond  the  stern  o  clavicular 

elation  ;  divide  the  sternal  portion  of  themus" 
cle  and  turn  it   backwards  ;  and   then   proceed  to 
te  the  artery  and  to  apply  the  ligature  as  di- 
ed under  the  Last  head. 
,    According  to  Non  id  artery  bae 


250  COMMON  CAROTID   ARTERY. 

ligated  T49  times,  and  with  a  Fatal  result  in  32 
cases.  The  most  common  cause  of  death  after 
this  operation  is  a  cerebral  disturbance,  which  fact 
can  be  readily  understood  when  the  pathological 
susceptibilities  of  the  brain  are  taken  into  the  ac- 
count together  with  the  important  functions  of  the 
carotid  as  the  great  blood  carrier  to  that  delicate 
organ.  Erichsen  gives  the  following  as  his  con- 
clusions in  regard  to  this  operation  : 

1.  Ligation  of  one  carotid  is  followed  in  about 
one  fifth  of  the  cases  by  cerebral  disturbance,  more 
than  one  half  of  which  are  fatal. 

2.  Ligation  of  both  carotids  at  the  same  time  in- 
variably results  in  death. 

3.  "When  both  carotids  are  ligated,  with  an  in- 
terval of  some  days,  there  is  not  more  clanger  than 
when  one  is  tied. 

4.  Pathological  investigation  has  shown  that 
even  if  both  the  vessels  be  gradually  obliterated  the 
patient  may  live. 

Jobert  and  filler  have  also  called  special  atten- 
to  the  fact  that  the  luugs  are  secondarily  affected 
after  the  ligation  of  the  carotids. 

When  the  carotids  are  ligated  the  head  is  sup- 
plied with  blood  by  means  of  the  vertebral  arteries, 
and  a  communication  which  exists  between  the  ar- 
teria — princeps  cervicis  a  branch  of  the  occipital,  and 
the  profounda  cervicis,  a  brauch  of  the  subclavian. 

Ligation  of  the  External  Carotid  artery. — The  com- 
mon carotid  of  either  side  divides  into  the  exter- 
nal and  internal  carotids  nearly  on  a  line  with  the 
upper  border  of  the  thyroid  cartilage. 

The  external  at  its  origin  is  slightly  in  front  and 


V 


EXTERNAL  CAROTID  ARTERY.         251 

to  the  inner  side  of  the  internal  carotid,  and  may 
be  found  without  much  difficulty,  by  tracing  up 
the  course  of  the  common  carotid  with  the  finger. 
Both  the  external  and  internal  are  sufficiently  su- 
perficial to  be  readily  reached,  by  the  Surgeon  ; 
.but  the  latter  is  not  a  proper  subject  for  operation 
for  many  obvious  reasons. 

The  external  carotid  has  numerous  and  impor- 
tant branches  conveying  blood'to  the  thyroid  gland, 
tongue,  pharynx,  face,  posterior  aspect  of  the  head, 
anterior  and  middle  portion  of  the  scalp,  carotid 
gland,  «&c. 

PLAN  OF  RELATIONS. 

In  front. — Integument,  platysma,  superficial  fascia,  deep 
fascia,  hypoglossal  nerve,  lingual  and  facial  veins,  digastric 
and  styto-hyoid  muscles,  facial  nerve,  parotid  fgland,  tempo- 
ral and  maxillary  veins. 

rnally. — Hyoid,  pharynx,  parotid  gland,  ramus  of  the 
jaw. 

-Superior  laryngeal  nerve,  styloglossus  muscle, 
styto-pharyngeus  and  glosso-pharengeal  nerves,  and  paroted 
gland. 

It  is  only  in  the  cervical  portion  that  the  artery 
is  tied,  just  below  the  digastric  muscle.  Above 
that  locality  the  operation  becomes  much  more 
difficult  and  dangerous  because  of  the  important 
parts  with  which  it  is  iu  immediate  relation. 

Directions. — Make  an  incision,  common* 
half  an  inch  below  the  angle  of  the  jaw  and  extend- 
ing as  low  as  the  middle  of  the  thyroid  cartilage 
and  running  parallel  with,  and  half  an  inch  from 
the  edge  of  the  sterno-clcido-mastoid ;  divide  the 
platysma  and  cervical  fascia  on  a  grooved  direc- 
tor;   separate  the    sheaths  of  the  submaxillary 


252  THYROID  ARTERY. 

upwards  and  forwards ;  lay  bare  the  digastric  and 
stylo-hyoid  muscles  at  the  bottom  of  the  wound, 
by  means  of  the  point  of  the  director  or  the  for- 
ceps and  draw  them  forward  with  a  blunt  hook  : 
hold  the  sides  of  the  incision  wide  apart,  carry 
the  nerve  and  vein  backward  with  the  end  of  the 
finger,  and  cautiously  open  the  sheath  of  the  ves- 
sel ;  and  then,  with  the  artery  isolated  apply  the 
ligature  by  means  of  an  aneurismal  needle.  Dress 
in  the  usual  manner. 

The  external  carotid  has  been  tied  successfully 
for  wounds,  for  aneurismal  enlargements  of  its 
branches,  in  resections  of  the  jaws,  and  for  tu- 
mours of  the  antrim,  and  for  removal  of  the  paro- 
tid gland.  Except  for  wounds  which  divide  it, 
there  is  much  doubt  as  to  the  propriety  of  the  op- 
eration, on  account  ot  the  secondary  hemorrhage 
which  almost  necessarily  follows  the  ligation  of 
a  large  artery  so  near  its  point  of  ramification ; 
and  with  such  extensive  anastomosies. 

Ligation  of  the  Superior  Thyroid  artery. — It  is  only 
necessary  to  remark  in  regard  to  this  artery  that 
from  its  position  on  the  neck,  it  is  divided  gener- 
ally in  abortive  attempts  at  suicide,  and  hence,  the 
only  operation  necessary  is  simply  one  for  secur- 
ing cut  extremities  in  the  existing  wound.  Should 
it  be  impossible  to  do  this  in  consequence  of  the 
effusion  of  blood  in  the  surrounding  cellular  tis- 
sue, and  the  heaving  motion  incident  to  respira- 
tion, ligation  of  the  common  carotid  becomes  ne- 
cessary. 

Ligation  of  the  JAngual  Artery. — This  is  a  branch 
ol  the  common  carotid  and  is  given  off  a  little 


•above  the  superior  thyroid,  from  whence  it  r 
to  the  tongue. 

[t   honld  be  ligs  t  oppositi 

pus  projection  upon  the  upper  border  of  tl 
corner  of  the  os-byoides,  one  or  two  Hi 
r  cornu. 
Directions. — Find  the  great  cornu  and  mak< 
incision  about  an  inch  and  a  half  in  length  through 
the  skin  and  platj 

lei  with  it:  push  up  the  sub-maxillary  gland  and 
find  the  tendon  of  th  trie  muscle,   and  the 

hypoglossal  nervs  ■  >•  and  divide   the 

muscle:  open  the  ofthearteryj  isolate  and 

te  it. 
This  is  a  difticuii  a  bul 

il  may  be  undertaken    in   wounds   and    in    o] 
tions  on  the  tong  ;•  sal  and   Mirault 

artery  for  the  p   rpose  of  arr< 
the  tongue — a  mo  .  nder- 

taking. 

Ligdlion  of  fin   I  t. — This  u  off 

jusi  above  tlie  lingual  and  si 
nioii  trunk  with  it.      i  I     rni 
:  ior  border  • 

d  by 
an 

e  branch' 
it. 

I  i.i 

(pU.'i  ti 

11 


254  SUBCLAVIAN   ARTERY. 

facial  nerve ;  open  the  sheath  ;  isolate  and  ligate 
the  artery. 

Ligation  of  the  Sybclavian  Artery. — The  subcla- 
vian of  the  right  side  arises  from  the  arteria  inno- 
minata,  opposite  the  articulation  of  the  clavicle 
with  the  sternum,  and  extends  to  a  point  just 
below  the  margin  of  the  first  rib.  On  the  left  side 
the  subclavian  rises  directly  from  the  arch  of  the 
aorta,  and  is,  consequently,  longer  than  the  other, 
and  more  deeply  seated.  It  follows  therefore  that 
the  two  vessels  must,  in  the  first  portion  of  their 
course,  differ  in  their  length,  their  direction,  and 
their  relations  with  neighboring  parts.  Asameans 
of  facilitating  the  study  of  this  vessel,  especially 
in  a  surgical  point  of  view,  the  subclavian  has  been 
divided  into  three  parts.  T]\e  first  portion  is  in- 
cluded between  the  origin  of  the  artery  and  the 
inner  border  of  the  scalenus  anticus  muscle;  the 
second  is  immediately  behind  the  scalenus  anticus 
extending  from  the  inner  to  the  outer  border  of 
that  muscle;  and  the  third  extends  from  the  outer 
margin  of  the  scalenus  to  the  lower  border  of  the 
first  rib. 

In  its  first  portion,  the  course  of  the  right  artery 
is  obliquely  upwards  and  outwards;  in  its  sectmd, 
it  is  transversely  outwards;  and  in  its  third,  ob- 
liquely downwards  and  outwards,  so  that  it  forms, 
between  its  terminal  points,  an  arch  whose  centre 
is  nearly  behind  the  scalenus  anticus  muscle. 

The  left  artery  passes  almost  perpendicularly 
upwards  to  the  scalenus  muscle  and  then  curves 
outwards  and  downwards  to  the  lower  border  of 


LAVIAN    ARTERY.  255 

the  first  rib.     Those  three   portions   will    be  con- 
sidered separately. 

RELATIONS  OF  THE  FIRST   PORTION  OF  THE  RIGtHI 
SUBCLAVIAN. 

In  front. — integument,  superficial  and  deep  fascia,  pli 
ma,  Bterno-mastoid,  sterno-hyoid,  and  Rterno— thyroid  mus- 
cled, internal  jugular  and    vertebral   veinB,    pneumogastric, 
phr«nir  and  cardiac  tier. 

Behind'—  Recurrent  laryngeal,  and  sympathetic  nerves^ 
longus-colli,  and  trs  rocess  of  the  seventh   cervical 

\  ertebra. 

Beneat /.. — The  pleura. 

The  relations  of  the  first  portion  are  not  inter 
eating  in  a  surgical  point  of  view  since  the  artei  • 
cannot  be  ligatured  on  account  of  its  greal  deptli 
and  close  connexion  with  the  pleura. 

On  the  righl  side  the  operation  has  been  per. 
formed  with  success;  but  it  should  never,  be  un- 
dertaken when  it  is  possible  to  ligate  the  arten 
either  in  its  second  or  third  portion. 

Directions. — Place  tin1  patient  upon  the  table  in 
a  horizontal  position;  make  an  incision  along 
inner  border  of  the  clavicle  :  make  a  second  along 
the  inner  border  of  the  sterno-cleido-mastoid,  meel 
Lag  the  first  at  right  angles  ;  divide  the  Menial  at- 
tachment of  the  muscle  and  turn  it  outwards  ;  cut 
through  a  few  small  veins,  and  divide  the  stern  o- 
hyroidand  thy-roid  upon  a  grooved  director,  in  the 
Bame  manner  mall  v  the  anterior  jugular  is  cm 

in  this  Btep  of  tie  on  ;  cut  through  the 

::   with  the  li 
jugular  vein,  which  ci  rter}  ;  press  this 

aside   and   Becure  the  artery,  by  passing  the   nee- 
dle  from  belt  oat  (»i<l  injni 
the  pleura. 


256  SUBCLAVIAN   ARTKKV. 

Take  care  to  avoid  the  recurrent  laryngeal,  the 
phrenic  and  sympathetic  nerves,  and  to  apply  the 
ligature  near  the  vertebral  artery,  so  as  to  secure 
as  much  room  as  possible  for  the  formation  of  a 
clot. 

Aneurisms  of  the  axillary  or  subclavian  artery 
encroaching  upon  the  scalenus  muscle,  or  wounds 
of  the  second  portion  of  the  artery,  may  possibly 
justify  this  operation  as  a  last  resort.  This  ishowe- 
ever  a  tedious,  difficult,  and  dangerous  procedure, 
andshouldnot  be  attempted  without  due  considera- 
tion and  for  the  most  cogent  reasons. 

PLAN  OF  THE  RELATIONS  OF  THE    SECOND     PORTION    OF 
THE  ARTERY. 

In  front. — Platysma,  sierijo-mastoid  and  scalenus  anticus 
muscles;   phrenic  nerve  and  cevvicle  fascia, 

Above. — Brachial  plexus  and  onio-hyoid. 

Below. — First  rib. 
'    Behind. — Scalenus  medius   muscle. 

Directions. — Place  the  patient  upon  a  table,  se- 
cure his  head,  and  see  that  his  shoulders  are  drawn 
downwards  and  slightly  forwards  ;  make  an  incis- 
ion immediately  above  the  clavicle  and  parallel 
with  its  posterior  border,  commencing  one  inch 
above  the  sternal  end  of  the  bone,  and  dividing  the 
external  fasciculus  of  the  sterno-mastoid  ;  find  the 
tubercle  on  the  rib  with  the  finger;  pass  a  director 
behind  the  scalenus  and  divide  it  thoroughly  ;  then 
the  artery  being  exposed  and  recognized  by  its 
general  course  and  pulsations,  pass  theneedle  from 
without inivard?)  and  apply  the  ligature.  Be  care- 
ful not  to  injure  the  phrenic  nerve,  the  internal  ju- 
gular vein,  and  the  internal  mamaiv  artery  whic 


MYTAN    ARTERY.  257 

on  the  in  nor  side  of  the  scalenus  anticus 
must  !<■. 

Th  of  flu  artery t  though  more  favorable 

tor  the  application  of  a  ligature  than  the^rstf,  is  far 
fr<>m  being  Hie  most  desirable  position  for  the  ope- 
ration, because  Of  the  intimate  relation  of  the  phren- 
ic nerve,  the  internal  jugular  vein,  and  the  internal 
mammary  artery  with  the  scalenus  muscle  which 
must  necessarily  be  divided.  There  is  also  anoth- 
er objection  which  is  based  upon  the  close  proximity 
of  the  artery  to  the  pleura, — a  structure  of  pecu- 
liar delicacy  of  organization-  Sometimes  the  ar- 
tery passes  in  iron!  oi  the  scalenus  m  scle,  and  oe- 
>nal)y  "through  its  fibres. 

PLAN     OF    THE  RELATIONS     0F    THE  THIRD  PORTION  OF 

THE     ARTERY. 

In  front. — Integument,  fascia,  platyama,  external  jugular, 
Bupra  e  nd  transverse  cervical  veins,  cervical    plexus 

Bubclavius  muscle,  supra  scapular  vessels,  and  clavicle. 
,   and  omohyoid. 
w  —  Firpt  rib. 

This  is  the  most  eligible  position  tor  the  perfor- 
mance of  the  operation. 

Directions.  Place  the  patient  upou  a  table4  with 
hi>  shoulder-  de]  and  his  head  well  secured  : 

draw  down  the  integuments  as  much  as  possible, 
upon  the  clavicle  ;  make  au  incision  through  the 
ski nj  thus  drawn  down,  to  the  hone  from  the  ante- 
rior !  ;;-  to  the  posterior  border 
of  the  storno-  ;  makes  short  vertical  incis- 
ion meeting  the  centre  of  the  preceding  one  at  a 
right              divide  the   platysraa    and   superficial 


258  .SUBCLAVIAN    ARTERY. 

fascia  upon  a  grooved  director;  hold  aside  the  in- 
ternal jugular  vein,  which  is  on  the  inner  side,  as 
well  as  the  scapular  and  transverse  cervical ;  avoid 
the  supra-scapular  artery,  and  find  the  omo-hyoid 
muscle,  and  hold  it  out  of  the  way  ;  divide  the  fas- 
cia with  the  finger  nail  or  scalpel  and  find  the  outer 
margin  of  the  scalenus  anticus  ;  and  then  pass 
the  finger  down  this  margin  until  it  strikes  the 
first  rib,  where  the  pulsations  of  the  artery  may  be 
felt,  as  it  passes  over  its  surface.  This  being  done, 
pass  the  aneurismal  needle  around  the  vessel  from 
before  backwards,  taking  care  not  to  include  a 
branch  of  the  brachial  plexus  in  the  ligature.  Re- 
member that  the  subclavian  vein  passes  almost! 
transversely  forwards  from  the  outer  margin  of  the 
first  rib  to  the  sterno-clavicular  articulation,  in 
front  of  the  artery,  being  separated  from  it  by  the 
scalenus  anticus  muscle  and  the  phrenic  nerve. 

IiCiiiarh.— That  portion  of  the  artery  which  is 
included  between  the  outer  margin  of. the  scalenus 
muscle  and  the  lower  border  of  the  first  rib,  is  al- 
ways selected  as  the  proper  site  tor  deligation, 
when  it  is  possible  to  do  so.  The  artery  in  its 
third  part  is  comparatively  superficial,  whilst  it  is 
most  remote  from  the  origin  of  the  large  braches, 
and  not  so  completely  environed  by  important 
vessels  and  nerves. 

This  operation  may  be  required  on  account  of 
aneurisms  or  wounds  of  the  axillary  artery  ;  and 
though  less  difficult  than  those  undertaken  at  the 
first  and  second  portions  of  the  vessel,  it  is  of  suffi- 
cient gravity  to  preclude  its  employment  save  in 
cases  of  paramount  necessity. 


ILIAC    ARTERIES. 

In  ordinary  cases  the  artery  is  not  at  a  great 
depth,  but  when  the  clavicle  is  elevated  from  the 
presence  of  a  large  aneurysmal  tumour,  it  is  then 
very  remote  from  the  surface,  and  the  difficulties 
of  the  operation  are  increased. 

The  circulation  of  the  limb  is  supported  after 
Ligature  of  the  subclavian,  principally  by  means  of 
the  superior  scapular  artery. 

In  persons  with  short  necks  the  first  rib  is  lower 
in  relation  to  the  clavicle,  and  the  artery  is  deeper 
while  the  very  opposite  of  this  is  true  in  persons 
with  longneeks. 

The  artery  i^  found  invariably  on  the  outside  of 
the  project  :ng  tubercle  or  the  first  rib,  which  gives 
attachment  to  the  scalenus  anticus  muscle. 

Ligation  of  the  Common  Hide  Arteries. — The  ab_ 
dominal  aorta  bifurcates  opposite  the  body  of  the. 
fourth  lumbar  vertebra  on  the  left  side  of  the  spi- 
nal column  and  forms  the  common  iliac  arteries. — 
These  are  about  two  inches  in  length,  and  diverge 
o\\  either  side,  running  downwards  and  outwards 
upon  the  margin  of  the  pelvi-,  and  dividing  oppo- 
site the  articulation  of  the  sacrum  with  the  last 
lumbar  vertebra,  into  the  i  sternal  and  internal  iliac 
arteries.  The  external  iliacs  are  distributed  to  the 
inferior  extremities  while  the  internal  iliacs  Bttpply 
the  viscera  and  parietes  of  the  pelvis. 

The  right  common  iliac  is  longer  and  more  ob- 
lique than  the  left.  In  front  it  is  covered  by  the 
peritoneum,  the  intestines,  and  the  branches  of  the 
sympathetic  nerve,  while  it  is  crossed  atitsdvision 
by  the  ureter.     Behind  \i\>  separated  from  the  last 


260  ILIAC    ARTERIES. 

lumbar  vertebra  by  the  common  iliac  veins.  On 
the  outer  side  it  is  in  the  relation  with  the  vena  cava 
the  right  common  iliac  vein,  and  the  psoas  raagn us 
muscle.  The  commencement  0f  this  vessel  corres- 
ponds with  the  left  side  of  the  umbilicus  on  a.  level 
with  a  line  drawn  from  the  highest  point  of  one 
iliac  rest  to  the  opposite  one,  and  its  course  to  a 
line  exi  nding  from  from  this  point  downward  to- 
wards , .  3  middle  pf  Pouparts  ligament. 

Dir<  iions. — Make  an  incision  from  four  to  live 
inche.  length,  from  about  two  inches  above  and 
to  the  ft  of  the  umbilicus,  outwards  in  a  curved 
direct-  i,  towards  the  lumbar  region,  terminating 
low  the  the  anterior  superior  spine  of  the 
ilium  :  livide  carefully  each  abdominal  muscle,  and 
the  tr<  sversalis  fascia  at  the  lower  part  of  the 
wound  separate  the  peritoneum,  together  with  the 
ureter.  ;  om  the  transversal  is  and  iliac  fascia,  and 
push  it  well  aside;  turn  the  patient  on  the  sound 
side,  d,  with  the  finger,  the  sacro-iliac  artic- 

ulation, over  which  the  pulsations  of  the  artery 
may  be  felt;  expose  the  artery,  together  with  its 
accompanying  vein,  which  is  in  the  sheath  and  on 
the  inner  side;  isolate  the  artery  and  pass  the  liga- 
ture under  it  from  u  rds. 

If  the  iliac  region  be  selected  for  the  operation, 
make  a  curved  incision  about  five  inch< 
length,  commencing  on  the  left  of  the  umbilicus 
and  carried,  first  outwards  towards  the  anteri- 
perior  spine  of  the  ilium,  and  from  them  along 
the  upper  border  of  Poupart's  ligament  to  its  mid- 
dle and  then  follow  the  directions  given  above. 


ILIAC    ARTERIES.  261 

Remarks. — This  operation  has  boon  performed 
with  mi  jcesa  though  it  is.  of  course,  both  difficult  of 
execution  and  dangerous  in  its  consequences.  The 
indications  i'ov  its  performance  are,  aneurisms, 
wounds,  involving  the  external  and  internal  iliac 
arteries,  or  secondary  hernowpiage  after  amputa- 
tion of  the  superior  third  of  the  thigh. 

it  is   of  the  first  inaportam  >id  wounding 

the  peritoneum,  lest  inllannrliion  be  developed  in 
that  delicate  and  susceptible  membrane,  and  thins 
add  another  source  of  danger  to  the  patient's  life. 
[t  should  be  carefully  held  aside,  by  the  finger  or  a 
r  spatula  in  the  hands  of  an  assistant,  and 
most  tenderly  hand!. 

According  to  Quaiu  the  length  of  the  vessel  va- 
riee  greatly, — rangingin  five  sevenths  of  the  cases 

between  one  and  and  a  half  and   three    inches. 

When  the  artery  is  found  to  be  very  short,  it  is 
better  to  tie  both  the  external  and  internal  iliacs 
below. 

The  points  of  importance  are  the  relations  of  the 
1  to  the  Lumba"  vertebra,  to  the  crest  of  the 
ilium,  to  the  umbilicus,  to  the  vena  cava  and  com- 
mon iliac  veins  of  the  right  side,  and  to  the  inner 
side,  [n  making  the  incision,  care  must  also  be 
taken  not  to  carry  it  too  Low  down  or  too  far  for- 
wards, as  in  doing  so  there  is  danger  of  wounding 
the  epigastric,  and  circumflex-ilii  arteries. 

Of  -  referred  to  by  Erichsen,  nine 

recovered. me '  died.      In  two  of  the  fetal  eas- 

es the  peritoneum  was  opened,  and  in  four  of  the 
others,  death  seemed  mere  the  result  of  the  orm-i- 

o 

nal    affection   than    of  the  operation.     When  the 


2P>2  ILIAC    ARTERIES. 

depth  of  theartery  is  considered,  together  with  its 
great  size,  the  force  of  the  blood  current  through  it, 
the  intimate  relations  sustained  by  it  to  important 
structures,  and  its  proximity  to  the  heart,  the  dan- 
gers and  difficulties  of  the  operation  must  be  suffi- 
ciently patent  ':o  inspire  the  Surgeon  with  caution 
and  apprehoay.ion  in  regard  to  it,  notwithstanding 
the  statis;.  i^,  ^formation  furnished  by  Erichsen 
and  others  in  tin-  connexion. 

Ligation  of  the  Internal  Iliac  Artery. — The  inter- 
nal iliac  artery  is  a  short  and  thick  vessel  which 
commences  at  the  bifurcation  of  Ihe  common  iliac, 
and,  passing  to  the  margin  of  the  greater  sacro-sci- 
atic  foramen,  divides  into  two  trunks,  which  are 
distributed  to  the  subjacent  parts. 

PLAN    or  RELATIONS. 

In  front. — Peritoneum  ami  ureter. 
Outer  side. — ■  Psoas  magnusmuscle, 

Behind. — Internal  iliac  vein,  lumbar  sacral  nerveand  p.^oas 
muscle. 

This  artery  and  the  common  iliac  as  regards  their 
length,  bear  an  inverse  ratio  to  each  othei%  the  one 
qeino-  long  when  the  other  is  short  and  vice.versa. 

The  point  of  division  oi  the  internal  iliac  varies 
between  the  upper  margin  of  the  sacrum  and  the 
upper  border  of  the  sacro-sciatie  forarnem. 

The  application  of  a  ligature  to  the  internal  iliac 
nuiv  be  required  in  cases  of  aneurism;  in  wounds 
affecting  one  of  its  branches, , or  in  hemorrhage  fol- 
lowing amputation  of  the  thigh,  &c. 

Directions. — Make  an  incision  through  the  ab- 
dominal parietes  in  the  iliac  region,  in  a  semilu- 
nar direction  and  to  the  same  extent  as  for  deliga- 


ILIAC    ARTERIES.  263 

tion  of  the  common  iliac;  cautiously  divide  the 
transversalis  fascia,  push  the  peritoneum  inwards 
from  the  iliac  fossa,  unci  distinguish  the  external 
iliac  at  the  bottom  of  the  wound  :  trace  thisartery 
up  until  the  internal  iliac  is  discovered  opposite 
the  sacroiliac  articulation:  separate  the  vein  on 
the  left,  iln*  external  illiac  on  the  right,  and  the 
peritoneum  and  ureter  in  front  of  the  v.  asel  ; 
open  the  sheath,  isolate  tin1  artery,  by  passing  the 
left  fore-Jinger  under  it  from  vide,  and  the 

from  the  outer  side,  and  then  hook- 
ing it  up  upon  the  finger,  or  grasping  it   between 
the  thumb  and  index  finger;  and,  finally  pass  the 
■  ure    around  it  from  within  outioards. 
Rt  This   operation    has  been   attended 

with  considerable  success,  but  all  that  was  said  in 
»ard  to  the  ligature  of  the  common  iliac  will  ap- 
p  with  almost  equal  force   to  this  deligation  of 

internal    iliac. 
One  of  the  cheif  dau  ft  om  j>  sritonitis,  and 

the  gr< .  re  should  be  taken  not  to  injure  the 

ritoneunf,  throughout  the  various  steps  of  the  op- 
eration.      Vs  soon  as  it  i  irered,  the  surgeon  or 

an  tuld  bold  it  carefully  aside,  and  its 

sepi  iration  i  title   tou  the  left 

fore  fing  sr,  in  the  direction  of  rtebral 

artie  ulation,  until    the  bed.     Too 

nun  id  caution   cannot  be  exercised 

in  i  It  is  import  ■  not  to  include 

the  ureter  in  the    ligature,  wb  ild  prove  a 

most    imfortuua  Theur  aesjust 

and  is  separa- 
ted \y|  ih  consid*  ifliculty  from  the  vessel. — 


^64  ILIAC   ARTERIES. 

distinguish  it,  however  ?  and  separate  it  or  abandon 
the  operation  so  that  upon  nature  and  not  surgery, 
may  rest   lie  responsibility  of  a  fatal  issue. 

In  m?  fing  the  first  incifcion,  great  care  should 
be  take-  not  to  divide  the  epigastric  artery,  or  to 
penetra  the  peritoneal  cavity,  as  may  be  readily 
done  w      re  the  muscles  are  not  poorly  developed. 

Ligc  i  z  of  the  External  Iliac  artery. — -This  is  the 
chief  vc  >el  by  which  the  lower  limb  is  supplied 
with  It  passes    obliquely  downwards  and 

outward  horn  the  bifurcation  of  the  common  iliac, 
along  tli  inner  border  of  the  psoas  muscle,  to  the 
femoral  arch,  where  it  becomes  the  femoral  artery. 
The  ci  of  this   arl  indicated   by    a 

drawn  fr  m  the  left  vide  of  the  umbilicus  to  a  point 
midway  between  tht  •  nor  spinous  pr 

of  theilium  and  the  symphysis  pvbes 

PLAN  OF  RELATION;?. 

Infr&nt. —  Peritoneum,  intestines  and  iliac  fascia,  spermat- 
ic vessels,  genito-crnral  nerve,  circumflex  ilii  vein,  symphatid 
vessel  and  gland. 

Outer  side. — Psoas  magnus  iliac  fascia. 

Inner  side, — External  iliac  vein  of  vas  deferens  ami  femoral 
arch. 

Behind. — External  iliac  vein. 

Ligation  of  the  external  iliac  artery  may  be  re- 
quired for  wounds  and  aneurisms,  of  the  femoral 
artery,  and  also  for  secondary  hemmorhag-e  follow- 
ing amputations,  when  all  oilier  means  have  failed 
in  arresting  the  flow  of  blood. 

The  vessel  may  be  secured  in  every  part  of  its 
course  save  near  its  upper  and  lower  extremities^ 
the  circulation  at  these  points  being  too   rapid  to 


ILIAC  ARTERIES.  265 

admit  of  the  formation  of  a  sufficiently  firm  clot 
to  meet  the  ends  in  view. 

Directions. — Place  the  patient   in   a  recumbent 
position;  make  an  incision,  commencing  an  inch 
above,  and  to  tho  inner  side  of  the  anterior  superi- 
or spinous  process  of  the  ilium,  and  running  down- 
wards  and  outwards,  to  the  outer  end  of  Poup 
ligament,  and  from  thence  parallel  with   its  outer 
half  to  a  little  above  the  middle  :  divide,  the  abdo- 
minal muscles  and  cut  cautiously  through  thutrans- 
versalis    fascia;  separate  the  peritoneum  carefulh 
from  the  iliac  fossa,  and  push  it  towards  the  pelvis  i 
introduce  t   e  index  linger,  and  find  the  artery  pul- 
sating at  the  bottom  of  the  wound  along  the 
border  of  the  psoas  muscle  :  separate  the  ilia< 
from  the  artery,  on  the  inner  side,  by  means  of  the 

c    nail  :  Oj  en   the    sheath,    isolate    the  artery 

ally,    and    pass  the  ligature  under  the  artery 
from  within  outwards,  i.  e.,  between  the  vein    and 
artery,    leaving    out  the  small  nerve  which  accom 
panies  the  latter. 
Remarks. — The  direction  of  the  external  incii 

een  much  varied  by  different  surgeons.     Thus 
Abernethy  cut  o 

sel  ;   Sir  A.  Cooper  made  the  incision  from  t1  ■ 
ternal  margin  of  the  external  ring  to  the  anterior 
superior  spinous  process  of  tb  following  the 

ion  of  Poupart's    ligament;  while  Velpeau 
modified  this  precedure,  without  improving  on   it 
in  the  I  • 
The  tbjection  to  Abernethy' s  plan   is  the 

'••'•  of  subse  [uenl  hernial  protrusion  in  conse- 
quence of  the  abdomen  beingmuch  weakened   by 


2<%  ILIAC  ARTERIES. 

the  free  incisions  through  its  muscular  fibres.  It 
lias  the  advantage  however  ofpermitting  the  dele- 
gation of  the  artery  at  any  portion  of  its  coarse, 
and  of  allowing  the  incision  to  be  extended  op- 
wards  if  necessary' 90  as  to  expose  the  common 
iliac. 

The  incision  recommended  by  Cooper  ts  direct- 
'  ly  across  the  track  of  the  epigastric  and  circumflex 
ilii  arteries,  as  well  as  the  circumflex  vein.  The 
spermatic  cord  is  somewhat  in  the  way  of  this 
operation.  Its  chief  recommendations  are  the  pro- 
tection afforded  to  the  peritoneum,  and  the  im- 
munity secured  from  subsequent  hernial  protru- 
sions. 

The  most  common  evil  followingthese  operations, 
hgangr£neoi the  limb,  resultingfrom  the  curtailment 
of  the  sanguinious  supply  to  the  part,  in  conse- 
quence of  the  obliteration  of  the  main  channel  and 
the  tardy  development  of  circuitous  ones.  The 
period  at  which  this  mortification  occurs  is  usually 
about  the  third  or  fourth  week ;  and  the  only 
means  of  saving  the  life  of  the  patient  is  a  speedy, 
resort  to  amputation. 

The  greatest  possible  attention-  must  be  be- 
stowed upon  the  preservation  of  the  peritoneum 
from  all  wounds  or  injury,  at  every  step  of  the  op- 
ration.  Peritonitis  is  one  of  the  mast  serious  (•■..im- 
plications by  which  the  Surgeon  can  be  embarrass, 
ed,  and  the  patient's  life  endangered. 

It  is  important  to  hava  the  incision  as  long  as 
practicable,  but  it  must  not  be  carried  far  enough 
to  implicate  the  external  ring,  lest  it  induce  a  ten- 
dency to  hernial  protrusion. 


ILIAC  ARTERIES.  267 

Before  beginning  the  operation  shave  thepubes, 
and  empty  the  colon  by  means  of  an  enema. 

This  operation  was  first  attempted  by  Aber- 
nethy,  in  1796,  and  since  that  period  it  has  been 
performed  at  least  loo  times,  with  a  mortality  of 
only  26  per  cent.  Sir  A.  Cooper  declares  that, 
"this  operation  may  be  performed  without  the 
least  difficulty,  and  is  as  easy  as  tying  the  femoral 
artery,  there  being  only  one  circumstance  that 
occasions  the  least  danger,  and  that  is  the  epi- 
gastric artery  which  passes  up  from  the  iliac-  ves- 
sel, and  on  the  inner  side  of  the  incision  ;  but  this 
however  may  be  avoided." 

The  distance  of  the  artery  from  the  surface,  the 
great  danger  of  wounding  the  peritoneum,  and  its 
close  proximity  to  important  veins  and  nerves,  as 
well  as  to  the  spermatic  oord,  all  goto  prove  that  the 
deligation  of  this  artery  is  a  more  serious  and  im- 
portant thing  than  is  supposed  by  Cooper,  and  to 
warn  the  conscientious  Surgeon  against  an  opera- 
tion into  which  the  mere  desire  for  eclat  might  pos- 
sibly  hurry  him. 

The  circulation  is  carried  on  after  the  ligation  of 
this  artery  by  means  of  the  gluteal  and  ischiatic 
arteries, — the  former  being  the  principal  one  con- 
cerned. 

It  cannot  be  denied  that,  operations  on  the 
iliac  vessels  generally,  are  far  more  success- 
ful than  upon  those  vessels  above  the  heart 
which  pertain  especially  to  the  trunk,  notwith- 
standing that  the  former  are  more  deeply  seated. 
surrounded  by  more  delicate  structures,  and  are 
even  oi'  larger  calibre. 


268  axillary  artery. 

Ligation  of  the  Arteries  of  the  Superior  Ex- 
tremity.— Ligation  of  the  Axillary  Artery. — The 
axillary  artery  commences  where  the  subclavian 
termiates,  at  the  lower  border  of  the  first  rib,  and 
becomes  the  brachial  at  the  lower  border  of  the 
tendon  of  the  latissimus-dorsi  and  teres  major 
muscle. 

In  the  normal  quiescent  position  of  the  limb,  the 
artery  forms  a  gentle  curve,  the  convexity  of  which 
is  outwards  and  upwards. 

For  convenience  of  description  this  artery  may 
be  divided  into  three  portions,  viz  :  the  portion 
above  the  pectoralis  major,  or  first  part;  the  por- 
tion beneath  the  pectoralis  muscle,  or  the  second 
part ;  and  that  portion  below  the  muscle  and  in  the 
axillary  space,  the  third  part. 

Eelations  the  first  portion  of  the  axillary  artery  : 

Infront. — Pectoralis  major,  costo-coraooid  membrane,  ce- 
phalic vein. 

Outer  side. — Brachial  plexus, 

Inner  side. — Axillary  vein., 

Behind., — First  intercostal  space  and  muscle,  first  serration 
ot  serratus  magnus,  posterior  thoracic  nerve, 

The  artery  maybe  tied  in  this  portion,  in  case 
of  aneurisms  or  wounds  of  the  second  portion,  but 
it  is  not  the  point  of  election.  In  some  few  cases 
it  has  been  performed  with  success,  but  it  is  always 
difficult  and  dangerous. 

Directions. — Place  the  patient  on  his  back,  with 
his  shoulders  slightly  raised,  and  his  elbow  a  little 
removed  from  his  body  ,  make  an  incision  three 
inches  long,  three  quarters  of  an  inch  below,  and 
parallel  to  the  clavicle,    and   terminating   at  the 


AXILLARY  ARTERY.  269 

junction  of  the  deltoid  and  pectoralia  major;  cut 
through  the  platysnia  and  pectoralia  carefully," lay- 
er by  layer ;  divide,  on  a  director,  the  posterior 
Sheath  of  this  muscle  which  doubles  back  and  lias 
the  appearance  of  an  aponeurosis;  then  bring  the 
arm  to  the  body,  and  with  the  end  of  the  director, 
or  the  handle  of  the  knife,  tear  aside  the  cellular 
>veriug  the  vessel,  and  carry  the  finger  be- 
hind the  upp<  oralis  mi 
cle  ;  draw  the  vein  inwards  by  means  of  a  blunt 
hook,  and  pass  the  iieedh  en  it  and  the  ar 
m  within  outwards. 

Remarks. — This  ligature  is  one  of  the  most  diffi- 
cult to  apply,  ,both  from  the  large  muscles  which 
have  to  be  cut  through,  the  depth  ofthe  vessel,  and 
and  the  number  oi  jels  which  have  to  be  di- 

vid( 

it  is  ofthe  first  importance  to  avoid  the  cephalic 
and  axillary  veins, — the  former  running  along  the 
external  border  of  the  pectoralis  major,  cro 
the  artery  to  join  the  axillary  on  the  inner 
side  of  that  vessel.  The  vein  is  an  admirable 
land  mark,  and  when  found  should  be  drawn  care- 
fully aside,  so  that  the  artery  maj  be  reached  a  lit- 
tle to  tin  iind  it. 

It.  is  better  to  tie  th  vian  in  the  third.part 

maud 
e  the  middle  por- 

lu  oeral 

pracl  upon  and  lying  the  \ 

d  below  th  ■  wound  should  be  rigidly   ad- 
:  to  under  all  cil 


270  AXILLARY  ARTERY. 

RELATIONS  01  THE  SECOND  PORTION  OF  THE  AXILLARY 
ARTERY. 

Infront. — Pectoralis  major  and  minor. 
Outer  side. — Brachial  plexus. 
Inner  side. — , Axillary  vein. 
Behind. — Subscapularis, 

The  brachial  plexus  surrounds  the  artery  and 
separates  it  from  direct  contact  with  the  veins  and 
muscles.  This  vessel  is  so  deeply  seated  and  so 
completely  surrounded  by  important  structures 
that  an  operation  for  its  ligation  is  very  seldom  at- 
tempted. Desau  It  and  Pelpceh. have  given  direc- 
tions for  the  proper  performance  of  the  operation, 
but  it  is  now  generally  condemned  because  of  the 
facts  mentioned  above,  and  the  additional  consider- 
ation of  the  great  depth  of  the  artery  and  its  close 
investment  by  important  nerves. 

RELATIONS  OF  THE  THIRD  PORTION  OF     THE     AXILLARY 
ARTERY. 

In  front. — Integument,  fascia,  and  pectoralis  major  muscle. 

Outer  side. — Coraco-braclnalis  median  nerve,  musculo-cu  ta- 
neous  nerve. 

Inner  side. — Ulnar  nerve,  interna!  cutaneous  nerve,  axillary 
vein. 

Behind — Subscapulars,  tendons  of  latiesirnus  dorsi  and  teres 
major,  spinal  and  circumflex  r.erves. 

The  artery  is  usually  ligated  in  this  portion,  be- 
cause it  is  more  readily  reached  and  easily  iso- 
lated. 

Directions. —  Place  the  patient  upon  a  bed  ;  sep- 
arate the  arm  from  the  side  and  supinate  the  hand  ; 
having  found  the  head  of  the  humerus,  make  an 
irmision  over  it,  through  the  integuments,  about 
two  inches  in  length,  and  a  little  nearer  the  poste- 
rior than  the  anterior  fold  of  the  axilla  ;  carefully 


WILLARY  ARTERY.  271 

dissect  through  the  fascia  and  areolar  tissue,  until 
the  median  nerve  and  axillary  vein  are  exposed; 
displace  the  former  to  the  outer,  and  the  latter  to 
the  inner  side  of  the  arm,  bending  the  elbow  so  as 
to  relax  the  muscles  ;  and  then,  having  isolated 
the  artery,  pass  the  needle  from  the  ulnar  to  the 
radial  side. 

Remarks. —  It  must  be  remembered  that  the  axill- 
ary artery  in  about  one  case  in  ten  gives  off  a  large 
branch  which  forms  either  one  of  the  arteries  of 
the  fore  arm  or  a  large  muscular  trunk. 

Ligature  of  this  artery  is  called  for  in  cases  of 
wounds  and  aneurisms  at  the  upper  part  of  the 
arm:  and,  when  circumstances  admit  of  its  appli- 
cation in  the  lower  portion  of  the  vessel,  the  oper- 
ation is  simple  and  e:i>\ . 

Ligation  of  the  Brachial  Artery.— This  artery 
commences  at  the  lower  margin  of  the  tendon  of 
the  teres  major,  where  the  axillary  terminates,  and 
extends  to  about  one  inch  below  the  bend  of  the 
elbow,  where  it  is  divided  into  the  radial  and  ul- 
nar. 

The  direction  ot  this  vessel  is  marked  by  a  line 
extruding  from  the  outer  side  of  the  axillary  space 
bo  a  point  midway  between  the  condylee  of  the  hu- 
merus, which  corresponds  with  the  depression 
along  the  inner  border  oi  the  coraco-brachialis  and 
bicejys  muscles.  Tn  the  upper  part  of  it.-  course,  the 
artery  is  less  interna!  to  the  humerus,  but  below, 
it  is  in  front  of  that  bone. 


272  BRACHIAL  ARTERY. 

RELATIONS  OF  THE  BRACHIAL  ARTERY. 
In  front. — Integument  and   fascia,  bicipital  fascia,  median 
basilic  vein,  median  nerve. 

Outer  sale. — Median  nerve,  coraco-bvachialis,  biceps. 
Inner  side. — Internal  cutaneous,  ulnar  and  median  nerves. 
Behind. — Triceps,  musculospinal  nerve,  superior   profunda 
artery,  coraco-brachialis,  bracialis  anttcus,  and    bend   of  the 
elbow. 

The  median  nerve,  at  the  upper  portion  of  it- 
course  is  external  to  it;  about  the  middle  of  tjie 
arm  it  is  mfroiit  of  the  artery  ;  and  further  down 
towards  the  elbow,  it  is  upon  the  inner  side  of  the 
vessel.  The  basilic  vein  is  at  first  on  the  inner 
side,  and  then  gets  in  front  of  the  artery,  and  lies 
in  the  line  of  it,  for  the  remainder  of  its  course. 

The  artery  is  accompanied  by  two  veins,  the 
vense  comites,  which  lie  within  the  sheath,  in  close 
contact  with  the  main  vessel,  and  arc  connected 
together  at  intervals  by  transversa  commu- 
nicating branches.  At  the  bend  of  the  elbow,  the 
brachial  artery  sinks  deeply  into  a  triangular  space, 
which  contains,  also,  the  radial  and  ulnar  arteries, 
the  median  and  musculo  spiral  nerves,  and  the 
tendon  of  the  biceps  muscle.  Occasionally  the  ar- 
tery is  divided  high  up  the  arm,  either  to  unite 
before  reaching  the  elbow  or  to  be  continued,  t« 
the  fore  arm  as  the  radial  and  ulnar  arteries. 

The  artery  may  be  ligatured  either  in  the  uppei 
third  of  the  arm  or  in  the  middle  third  of  that  mem- 
ber. In  the  upper  portion  the  coraco-brachialit 
muscle  is  the  guide  for  the  operation  ;  while  in  the 
lower  portion  the  inner  margin  of  the  biceps,  furnish- 
es the  proper  indication. 

Directions  for  applying  the  ligature  in  the  uppei 
portion.-— Place  the  patient  horizontally  upon    the 


BRAOHIA]     JlRTEB  273 

table,  raise  the  affected  limb  from  the  side,  and  su- 
pinate  the  hand  ;  make  an  incision  two  inches  in 
length  on  the  ulnar  side  of. the  coraco-brachialis 
muscle, anddividcthe  fascia  carefully  as  high  as  the 
axilla  :  rut  carefully  through  the  cellular  tissue  and 
separate  the  ulna  nerve  on  the  inner  side,  the  med- 
ian on  the  outer  side;  open  the  sheath,  and  detach 
the  vena?  comites  which  are  on  either  side  of  the 
vessel  ;  and.  then,  pass  the  aneurismal  needle  un- 
der the  artery  from  the  ulnar  to  the  radial  side. 
The  vein  is  on  the  inner  side,  and  should  be  care- 
fully avoided-  Lisfranc  recommends  that  the  posi- 
tion of  the  median  nerve  should  be  found,  and  thai 
then,  placing  the  four  lingers  of  the  left  hand,  an 
incision  should  be  made  on  the  inner  side  ot  it. 
('arc  should  be  taken  in  every  operation  to  ascer- 
tain whether  there  are  two  arteries  in  the  arm, 
consequent  upon  a  high  division  of  the  main  trunk, 
and.  in  such  a  contingency,  to  ligature  both  of 
'  them. 

Directions  for  applying  the  ligature  in.  the  mid- 

the  arm. — Place  the  patient  horizontally  up- 

blc,  with  the  attected  limb  raised    from   the 

side;   make  an  incision  along  the  inner  margin   of 

■   biceps  muscle,  two  indies  and  a  half   in  'length 

ily  including  the  skin  ;  open  the  brachial    appn- 

rosis  and  carefully  carry-  the  basilic  vein  out    of 

ic  way:  then  find  the  median  i  erve  which   is  im- 

diately  on  the  edge,  of  the  muscle  ami  above  the 

and  draw  it  and  the  muscle  aside,  with  the 

blunt  In. ok  :  carefully  avoid  the  interna]  cutaneous 

nerve  on  the  inner  side  of  the  VCBael,  and  open  the 

eath  of  the  vess<  1  ;   then   separate  the  venae  com- 


"274  BRACHIAL  ARTERY. 

ites  isolate  the  artery,  and  pass  the  needle  under  it 
from  iviihin  outwards. 

The  lower  ipart  of  the.  artery  is  interesting  be- 
cause of  its  connexion  with  the  veins  usually  opened 
in  venesection.  The  median  basilic  vein  passes 
immediately  in  front  of  the  artery,  only  being  sep- 
arated from  it  by  the  fibrous  expansion  given  off 
from  the  tendon  of  the  biceps  to  the  fascia  covering 
the  flexor  muscles.  It  is  important  therefore,  not 
to  open  this  vein,  if  either  of  the  others  be  large 
enough  to  justify  an  operation,  lest  the  artery  be 
injured  by  the  lancet.  Should  it  become  necessary, 
however,  to  open  it,  great  care  should  be  observed 
by  the  Surgeon,  not  to  wound  the  artery,  &c. .  If 
the  vein  is  parallel  with  the  artery,  pronate  the  hand 
violently,  so  as  to  increase  the  distance  between 
the  two  vessels,  and  if  the  muscles  are  in  the  way 
flex  the  fore  arm  slightly,  for  the  same  pur- 
pose. When  the  vein  is  situated  immediately 
over  the  artery,  introduce  the  lancet  horizontally, 
and  compress  the  artery  at  the  moment  of  bleeding. 
Should  the  artery  be  punctured,  the  bleeding  may 
be  arrested  temporarily,  at  least,  by  flexing  the  fore 
arm,  putting  it  in  a  state  of  pronation,  and  apply- 
ing a  compress  over  the  wound.  It  is  well  also  to 
qandage  the  whole  limb. 

Remarks. — As  this  is  the  main  arterial  branch 
by  which  the  arm,  the  most  useful  and  exposed  of 
all  the  members,  is  supplied  with  blood,  it  follows 
that  its  deligation,  both  on  account  of  injury  and 
disease,  is  a  task  of  very  frequent  performance.  In 
the  battles  before  Richmond,  the  number  of  wounds 
received  in  the  arm  was  the  subject  of  universal  re- 


BADI'AI  ARTERY.       •  275 

mark.  No  accurate  statisical  information  has  yet 
been  furnished  in  regard  to  this  subject,  but  the 
author  feels  assured,  from  his  own  personal  obser- 
vation, as  well  as  the  assurances  of  others,  thai  of 
all  the  operations  performed  upon  the  jield,  at  least 
half  were  for  injuries  of  the  superior  extremities. 
The  management  of  the  musket  and  the  sabre,  the 
removal  of  obstructions,  &C.,  necessitate  the  con- 
stant use  and  exposure  of  the  arms,  and  thus  fur- 
nishe  an  explanation  of  the  fact  just  mentioned. 

Again,  the  brachial  artery  is  verY  frequently  in- 
jured in  venesection,  both  by  direct  puncture,  and 
development  of  aneurisms,  so  as  to  require  the  ap- 
plication of  the  ligature. 

The  operation1  may  be  readily,  rapidly,  andsafely 
performed,  if  the  anatomical  relations  of  the  parts 
are  properly  understood,  and  remembered. 

Ligation  of  the  Radial  Artery. — The  radial  artery, 
judgingfrom  its  position,  is  a  veritable  continuation 
of  the  brachial,  though  it  is  smaller  in  size  than  the 
ulnar.  It  commences  at  the  bifurcation  of  the 
brachial,  an  inch  below  the  bend  of  the  elbow, 
passes  along  the  radial  side  of  the  tore  arm  to  the 
wrist,  then  runs  backwards  round  the  outer  side 
of  the  carjms,  beneath  the  extensor  tendons  of  the 
thumb,  and  runs  forward  between  the  two  heads 
of  the  first  dorsal  interosseous  muscle  into  the 
palm  o\'  the  hand.  Aiter  reaehing  tin- palm  it 
form*  with  th  inch  oftheulnar,  the  deep  pal- 

it  may  be  therefore  divided,  for  conve- 
nience of  description,  into  three  papts,viz  :  that 
'on  in  fnmt  of  i:  rm;  that  at  thebaekof 

tlir  wrist;  and  thai  in  the  hand. 


27  G  RADIAL  ARTEL  i. 

RELATIONS  OF   THE  RADIAL  ARTERY. 

In  front. — Integ'iment,  fascia  and  supinator  longus. 

Outer  side. — Supinator  longus,  radial  nerve,  (middle  third.) 

. — Pronator  radii  teres,  flexor  carpi  radialis. 
Behind. — Tendon  of  biceps,  &c. 

In  the  upper  third  of  its  course,  it  lies  between 
the  pronator  radii  teres  aud  the  supinator  longus  ; 
and  in  the  lower  third,  between  the  tendons  of  the 
supinator  longus  and  the  flexor  carpi  radialis. 

In  the  middle  third  of  its  course,  the  radial  nerve 
lies  along  the.  outer  side  of  the  artery;  and  some 
filaments  of  the*  musculocutaneous  nerve  run 
along  the  lower  part  of  the  artery  as  it  winds  around 
the  wrist.  The  vessel  is  accompanied  by  vena; 
comites  throughout  its  coure 

This  artery  is  tied  for  wounds  and  aneurisms. — 
The  tendon  of  the\  pi  radialis  is  the  the  guide 

for  the  operation  in  the  middle  and  lower  parts  of 
the  arm. 

Directions  for  applying  a  ligature  in  the  lower 
third  of  the  fore  arm. — Make  an  incision  from 
half  an  inch  above  the  wrist  joint,  two  inches  in 
length  on  the  radial  side  of  the  tendon  of  the  flexor 
carpi  radialis ;  divide  with  another  incision  the 
aponeurosis  of  this  tendon ;  open  the  sheath  and 
separate  the  vense  comites ;  and  then  isolate  aud 
ligate  the  artery  by  passing  the  needle  from  without 
inwards. 

Directions  for  applying  a  ligature  on  the  upper 
third  of  the  fore  arm — Make  an  incision  two  inch- 
es and  a  half  in  length,  beginning  at  a  point  half 
an  inch  outside  of  the  middle  of  the  elbow,  this 
should  divide  the  skin  only,  for  fear  of  injuring  the 
median  vein,  which  ordinarily  is  on  the  inner  side 


RADIAL  ARTERY.  277 

make  another  incision,  laying  bear  the  supinator 
longus  ;  raise  the  internal  border  of  this  muscle 
with  the  linger  or  director  :  then  open  the  sheath 
isolate,  and  ligate, — passing  the  needle  from  with- 
out inwards  so  as  to  avoid  the  nei 

Directions  for  applying  the  ligature  on  the  dor- 
sum of  the  wrist. — Extend  the  thumb  Btronelv,  so 
as  to  cause  the  abductor  longus,  and  extensor  lon- 
gus pollicis  to  become  prominent;  seek  for  the  ar- 
tery in  the  depression  between  these  muf 
known  as  tk  la  taba  parate  the  thumb  from 

the  index  finger,  and  make  an  incision  about  an 
inch  loug,  in  the  direction  of  the  tendons  above 
referred  to;  separate  the  nervous  filaments  and 
veins  carefully  ;  and  then  isolate  the  artery  and 
apply  the  ligature. 

The   artery  is    readily  exposed   throughout   its 
who'  .  but  the  operation  in  tho  upper  third 

is  atl ended  with  more  difficulty  than  at  other  por- 
tions of  the  vessel,  on  account  of  its  greater  depth, 
and  the  position  of  the  supinator  longus  muscle. 

The  operation  upon  the  dorsum  of  the  thumb  is 
fit  only  for  the  dis  >m. 

[t  is  useless  to  lig     are  the  radial  artery   on    ac- 
count ofhemorrl]  :her  the  superficial  or 
■  palmar  arch,  as  the  supply  of  blood  from 
one  direction  only  is  thus  cut  iving  a   chan- 
iqually  as   broad   and   (hep,   communicating 
with  the  severed  artery.              -  such  cir.<  umstan- 
ces,  as  wcil  as  tor  am               and    wounds  of  the 
hand  and  Pore  aim   generally,   the    brachial    mu&t 
he  Ligatured.     In  woun  Is,  she  general    rule   must, 
be  followed  of  applying  the  ligatures  at  the  seat  of 
I -J 


ULNAR  ARTERY. 

:  ajury,  both  above  and  below  the  divided  surface 
ci'  the  vessel ;  and  when  this  is  impossible,  either 
compression  or  ligature  of  the  brachial  must  bo 
substituted. 

The  origin  of  the  radial  varies  in  the  propor- 
tion of  one  in  eight  cases.  Sometimes  its  point 
of  origin  is  lower   but  more  frequently  higher  up. 

It  is  thought  by  some  Surgeons  that  the  liga- 
tion of  the  artery  should  not  be  attempted  above 
the  middle  third,  as  the  operation  in  the  upper 
third  is  not  only  difficult,  but  calculated  seriously 
pair  the  integrity  of  the  muscles. 

Ligation  of  the  Ulnar  Artery. — This  is  the  larger 
of  the  two  terminal  branches  of  the  brachial.  It 
commences  a  little  below  the  elbow,  then  crosses 
the  inner  side  of  the  fore  arm  obliquely  to  the 
commencement  of  its  lower  half,  and  runs  along 
the  ulnar  side  of  the  wrist,  until  it  enters  the  palm, 
by  crossing  the  annular  ligament,  on  the  outer 
side  of  the  pisiform  bone.  After  reaching  the 
hand,  it  forms  with  the  superficialis  vohe,  a  branch 
of  the  radial,  the  superficial  palmar  arch. 

RELATIONS  OF  THE  ULNAR  ARTERY. 

In  front. — Superficial  flexor  muscles,  median  nerve,  superfi- 
cial and  deep  fascia. 

side. — Flexor  sublimis  digitorum. 
r  side. — Flexor  carpi  ulnar  is,  ulnar  nerve,  (lower  f.) 
J. — Brachialis  anticus,  profundus  digitorum. 

'he  wrist  the  ulnar  artery  is  covered  by  integ- 
uments and  fascia,  and  lies  upon  the  anterior  an- 
gular ligament,  with  the  pisiform  bone  and  ulnar 


IRTERY.  279 

nerve  on  the  inn<  r  swfc,-    the  latter  being  somewhat 

behind  the  vessel. 

The  ial palmar  arch    is  covered    by    the 

palmaris  brevis,  the  palmar  fascia,  and  the   integ; 
utnent. 

Direction. — The  artery  is  deeply  seated 
in  the  upper  half  of  the  fore  arm,  beneath  the  su- 
perficial flexor  muscles,  which  in  cases  of  recent 
wounds,  may  be  divided,  but  under  no  other  cir- 
cumstanc 

In  the  middlt  and  inferior  thirds  of  the  lore  arm, 
this  vessel  may  be  secured  in  this  manner:  Make 
an  incision  on  the  radial  side  erf  the  tendon  of  the 
flexor  carpi  ulnaris;  divide  the  deep  fascia,  and 
separate  the  flexor  carpi  ulnaris  from  the  flexor 
sublimis;  open  the  sheath,  separate  the  veins,  iso- 
late the  artery,  and  pass  the  needle  from  the  ulnar 
to  the  radial  side,  taking  care  not  to  injure  the 
ulnar  nerve. 

This  artery  may  he  deligated  in  cases  i^l'  aneu- 
risms,  wounds.  i  •..  in  either  of  its  main  trunks  or 
branchi 

It  should  not  be  ligatured  above  the  middle  third 
save  in  exceptional  cases  of  injury,  for  fear  of  per 
manently  injuring  the  superficial    flexor    muscle, 
which  must  necessarily  he  cut  through  in  the  ope- 
ration. 

In  wounds  of  the  palmar  arch,  it  is  better  to  seek 
tor  the  bleeding  and    to  ligature  each,  as 

com]  roduce  much  irritation  and  at  best  are 

rather  paliativetlian  curative  measures. 

If  the  hemorrhage  cannot  If  arrested  in  thin  was . 
both  the  radial  and  ulnar,  or  the  brachial  alone  may 


280  FEMORALJARTERl . 

be  tied,  which  will  effectually  arrest  the   flow   of 
blood  from  the  part. 

When  a  compress  is  used  for  hemorrhage  from 
the  palmar  arch,  it  should  be  in  the  shape  of  a  ball 
— the  hand  being  made  to  grasp  it  firmly  and  the 
graduated  compress  applied  to  the  arm,'  for  the  pur- 
pose of  diminishing  the  amount  of  blood  sent  to 
the  part, 

Ligature  of  the  arteries  of  the  inferior  ex- 
tremity.— Ligation  of  the  Femoral  Artery. — The 
femoral  is  a  continuation  of  the  external  iliac,  and 
extends  from  Poupart's  ligament  to  the  middle  of 
the  lower  third  of  the  thigh,  where  it  becomes  the 
popliteal.  It  commences  at  a  point  midway  be- 
tween the  anterior  superior  spine  of  the  ilium,  and 
the  S}'ph.  pubes,  passes  down  the  inner  aspect  of 
the  thigh,  and  penetrates  (he  adductor  ma-gnus 
•hiuscle.  A  line  drawn  from  the  point  just  referred 
to,  i.  e.,  midway  between  the  anterior  superior 
spine  of  the  ilium,  and  the  syph.  pubes,  to  the 
inner  side  of  the  internal  condyle  of  the  femur 
corresponds  with  the  direction  of  the  artery,  and  is 
nearly  above  and  parallel  to  it. 

In  the  upper  part  of  the  thigh ,  the  artery  is  very 
superficial,  and  lies  in  ".Scarper 's  triangle."  This 
triangle  is  bounded  thus  :  external/.//  by  the  sartor- 
ius  muscle,  internally,  by  the  adductor  lung  us,  and 
above  hy  Poupart's  Ligament,  which  is  its  base,  its 
apex  being  downwards.  This  triangle  corresponds 
to  the  depression  seen  immediately  below  the  fold 
of  the  groin,  and  is  nearly  equally  divided  by  the 


FEMORAL     ARTERY.  281 

femoral  artery  aud  vein  which   run    from    base   to 
apex. 

In  this  space  the  artery  is  crossed  in  front  by  the 
crural  branch  ofthe  genito  crural  nerve,  and  be- 
hind by  tlie  branch  to  the  pectineus  from  the  ante- 
rior crural  nerve  :  while  the  anterior  crural  nerve 
lies  about  half  an  inch  to  the  outer  side,  imbedded 
between  the  iliacus  and  psoas  muscles,  The  vein, 
which  is  included  in  the  sheath  with  the  artery,  is 
on  the  inner  side,  the  vessels  being  separated  from 
each  oilier  by  a  thin  fibrous  partition. 

En  the  middle  third  ofthe  thigh,  the  artery  is  less 
superficial;  being  covered  by  the  integuments  and 
fascia,  and  overlapped  by  the  sartorious  muscle. — 
also  enveloped  in  an  aponeurotic  canal  formed 
by  a  dense  band  which  extends  from  the  vastus 
interims  muscle  to  the  tendons  of  the  adductor 
longus  and  magnus. 

The  femoral  vein  passes  beneath  the  artery,  and 
lies  upt  n  its  oiidr  side:  and  still  more  externally,,  is 
the  the  long  saphenous  nerve,  but  not  included  in 
ame  sheath. 

Ligatures  are  frequently  applied  to  the  femoral 
artery,  princi]  allj  for  aneurisms  and  wounds,  and 
the  vessel  may  i  ited    at    any  point   in    its 

course.  Theoperation  is  however  much  more  dif- 
ficult in  the  middle  third  thigh  than  in  the 
upper  part  of  the  course  ofthe  artery,  because  of 
reater  depth,  and  the  thickness  of  its  aponeu- 
rotic covering. 

The  artery  may  be  tied  : 

1.  Above  the  origin  ofthe  profunda. 

2.  In  the  triangle  of  Scarpa,  just  above  the  point 


282  FEMORAL   ARTERY. 

where  the  artery  is  crossed  by  the  sartorious  mus- 
cle. 

3  Under  the  sartorious,  j  ust  below  the  apex  of  the 
triangle,  where  the  artery  is  only  slightly  overlap- 
ped by  the  muscle. 

4  Under  the  sartorins,  in  the  middle  part  of  the 
thigh. 

5  At  the  outer  side  of  the  sartorious,  below  the 
middle  of  the  thigh,  when  the  vessel  is  lodged  in 
the  sheath  formed  by  the  adductor  magnus  mus- 
cle. 

Of  these  various  points,  the  one  just  below  tJie 
apex  of  the  triangle,  where  the  artery  is  slightly  over- 
lappedby  the  muscle,  presents  the  fewest  difficulties, 
and  the  greatest  advantages.  This  point  is  about 
U  inches  from  Poupart's  ligament,  and  is  suffi- 
ciently below  the  origin  of  the  profunda  to  admit 
of  the  speedy  formation  of  a  firm  coagulum  wTithin 
the  vessel.  The  artery  can  also  he  readily  reach- 
ed at  this  point,  as  it  is  only  covered  by  the  in- 
ner edge  of  the  sartorins  which  can  easily  be 
raised,  while  it  serves  as  a  guide  to  the  operator. 

Directions. — Place  the  patient  upon  his  back, 
with  the  pelvis  slightly  elevated;  isolate  the  thigh 
outwards,  and  partially  rlex  the  limb  ;  follow  the 
course  of  the  artery  to  the  apex  of  Scarpa's  triangle 
where  it  ceases  to  pulsate  and  is  covered  by  the 
sartorins.  The  ligature  is  to  be  applied  about  fof 
an  inch  below  this  point.  Make  an  incision  three 
inches  long  commencing  lour  ringers'  breadth  be- 
low the  fold  of  the  groin,  and  running  directly- 
over  the  course  of  the  artery  ;  look  for  the  great 
saphena  vein,  in  the  superficial  fascia,  at  the  inner 


MORAL    LRTERY. 

side  oi  the  incision,  and  carry  it  carefully  to  one 
aide;  divide  the  superficial  fascia  upon  the  groov- 
ed director  ;  open  the  cellular  tissue  beneath  with 
the  point  of  the  director,  for  the  whole  length  of 
the  wound:  puncture  the  fascia-lata. which  comes 
in  view,  and  divide  it  on  the  director  for  about 
half  the  extent  of  the  iirst  incision  ;  then  draw  the 
inner  edge  of  the  sartorius  outwards;  open  the 
sheath  oftheartery,  isolate  the  vessel,  and  pas 
aneurism  needle  carefully  lest  the  vein  which  is 
posterior  to  the  artery  be  wounded. 

The  application  of  a  ligature  to  the  femoral  arte- 
ry ma}  be  requiredin  aneurism  or  wound 
oi  the  arteries  of  the  leg,  or  when  hemorrhag 

istent"  character   follows   amputations  of  the 
lower  extremity . 

Larreytied  it  above  the  profunda  before  am 
tating  at   the  hip  joint,  but  subsequent  exper 
has  demonstrated  that  this  is  an  unnecessary  com- 
plication,— increasing  materially  the  difficulty  and 
danger  of  (he  operation. 

It  is  ;i  matter  of  importance  not  to  apply  the  lig- 
ature in  the  neighborhood  of  a  large   branch 
by  so  doing,  the  m  of  the  blocking  <■< 

lum  be  prevented. 

The  deligation  of  the  artery  within  the  sheath  of 
the  adductor  maguus  ie  to  be  avoided   becaue 
the  difficuly  of  reaching  the  vessel,  and  the  u 
sibility  of  preventing  the  the  accumulation  of  pus 
within  the  wound.     The  poinl  indicated  aim- 
incomparably  the    best   for  the  operation. 

In  opening  the  sheath  of  the  artery,  care  sh 
oid  a  small  nerve  which  en 


284  FEMORAL   ARTERY. 

and  ah  not  to  make  too  large  a  wound,  lest  the 
nutrition  of  the  coats  of  the  vessel  he  interfered 
with,  a  I  muscular  branches,  which  are  irregular 
in  their  erigiu,  divided. 

In  order  to  avoid  the  femoral  vein  which  lies  be- 
hind and  somewhat  on  the  inner  side  of  the  artery 
the  needle  should  be  passed  from  within  outwards, 
the  inner  side  of  the  sheath  being  at  the  same  time 
put  upon  the  stretch.  Wounds  of  this  vein  are  tiie 
most  serious  accidents  which  associate  themselves 
with  this  operation,  and  are  usually  fatal,  producing 
phlebitis  or  gangrene. 

The  ligature  of  the  temoral  artery  is  attended 
with  more  success  than  of  any  of  the  large  trunks 
of  the  body,  as  is  established  by  the  statistics  of 
published  cases.  In  100  cases  collected  by  Dr. 
Crisp,  only  12  were  reported  to  have  died.  Secon- 
dary hemorrhage  and  gangrene  are  perhaps  the 
most  frequent  accidents  which  follow  this  opera- 
tion, and  jeopard  its  success. 

Should  secondary  hemorrhage  occur,  four  plans 
of  treatment  are  open  to  the  Surgeon,  viz  :  the 
employment  of  pressure  ;  the  ligature  of  the  vessel 
at  a  higher  point ;  the  delegation  of  the  bleeding 
orifice  in  the  wound  ;  or  amputation  of  the  limb. 
In  determining  what  course  to  pursue  in  such  a  con- 
tingency, the  Surgeon  must  follow  the  light  of  his 
own  judgment,  as  no  general  rules  can  be  estab- 
lished on  the  subject,  and  each  case  prevents  fea- 
tures  sui  generis  such  as  furnish  the  clue  to  the 
proper  method  of  treatment. 

After  the  ligature  has  been  applied,  the  edges  of 
the  wound  should  be  brought  together  with  adhe- 


FEMORAL      ARTERY.  285 

sive  plaster  and  stitches,  and  the  limb  semi-flexed, 
Bomewhal  raised,  and  wrapped  in   soft    flannel   or 

COtt<  ■ 

The  severe  pain  about  the  knee  which  follows 
this  operation,  may  be  relieved  by  the  exhibition 
of  full  doses  of  opium  1>\  the  mouth,  or 'the  admin- 
istration of  morphia  subcutaneously. 

Ligation  of  the  Popliteal  artery. — The  popliteal 
artery  extends  from  the  tefminatii  n  of, the  femoral 
at  the  opening  in  tire  abductor  magnns,  to  the  low. 
er  border  of  the  popliteal  space,  where  it  divides 
into  the  anterior  and  posterior  tibial  arteries.  This 
Bpace*is  l<  and  is  bounded  thus:  Ex. 

the  joint  by  the  biceps,  and  below  the 
articulation,  by  the  plantaris  and  the  external  head 
of  the  gastrocnemius.  Internally,  above,  the  joint, 
by  the  semi-membranosus,  semi-tendinosus,  gra- 
cilis and  sartorius  ;  and  below,  by  the  inner  head  of 
the  gastrocnemius.  A.bpve  it  is  limited  by  the 
apposition  of  the  inner  and  outer  hamstring  mus- 
and  below  by  the  junction  ofthe  twoheadsof 
tin1  gastrocnemius. 

The  artery  i  d  superficially  above    by   the 

6emi-membranosus ;  in  the  middle  of  its  course,  by 
a  quantity  if  fat  ;  and  below  by  the  margins  of  the 
gastrocnemius,  plantaris  and  soleus  muscles,  the 
popliteal  vein  and  internal  popliteal  nerve  The 
win  is  -  •  rnal  to  it  until  near  the 

termination  of  its  course  when  it  over,  and 

on  its  inn  The  nerve  is  still  more  su- 

perficial and  external,  bul  Grosses  the  artery  below 
the  joint,  and  then,  remains  upon  its  inner  side. 
12b 


28fi  PfiMORAL  ARTERY. 

Laterally  it  is  bounded  by  the  muscles  -which  fbrifl 
the  confines  of  the  popliteal  space.  • 

The  operation  may  be  performed  in  the  upper  or 
the  loioer  part  of  its  course ;  but  in  the  middle  of  the 
space,  its  deligation  is  attended  with  much  diffi- 
culty from  the  great  depth  of  the  artery,  and  the 
tension  of  its  lateral  boundaries. 

Directions  for  the  upper  part  of  its  course.  Place 
the  Patient  in  the  prone  position  and  extend  his 
limbs;  make  an  incision  three  inches  in  length 
through  the  integument  along  the  posterior  border 
of  the  semi-membranosus;  divide  the  fascia  lata 
and  draw  the  muscle  inwards;  find  the  artery  by 
means  of  its  pulsations;  separate  the  vein,  which 
is  on  the  inner  side,  and  the  nerve  on  the  outer 
side,  from  the  artery,  taking  care  to  injure  neither 
the  one  nor  the  other;  isolate  the  artery,  and  pass 
the  needle  from  without  inwards. 

Directions  f of  Loioer  portion  of  its  course.  Place 
the  patient  as  before  ;  make  an  incision  through 
the  integument,  and  in  the  middle  line,  com- 
mencing opposite  the  bend  of  the  knee  joint,  taking 
care  to  avoid  the  saphena  vein  and  nerve;  divide 
the  deep  fascia  on  the  grooved  director,  and  break 
up  the  cellular  tissue  with  its  point;  separate  the' 
vein  and  nerve  from  the  artery,  by  drawing  the 
one  outwards  and  the  other  inwards;  isolate  the 
artery  and  pass  the  needle  from  without  inwards. 

Remarks. — Ligature  of  the  Popliteal  should  only 
be  attempted  for  wounds  of  that  vessel;  but  for 
aneurisms  below  the  joint,  it  is  far  better  to  tie  the 
femoral  above.  The  Popliteal  space  is  so  filled 
with  important  structures,  and  the  vein,  nerve  and 


BRI0R  XIBIAt  AKTERT. 

artery  are  in  such  close  contact,  that  some  of  t< 
best  Surgeons,  declare  it  is  best  not  to   open   th  - 

e  even  in  punctured  wounds  of  the  Poplite 
artery. 

Operations  in  this  space  are  also  likely  to  lea  . 
burrowing  abscesses  which  may  involve  the  jo-" 
and  produce  the  most  serious  consequences. 

Ligation    of  the   Anterior    Tibial ,  Artery '. — The 
Anterior  Tibial  Artery  extends  from   the  point  vt 
which  the  Popliteal  bifurcates,  to  the  front  of 
ankle  joint  where  it  becomes  the  Dorsalis  Pi 
A    line  drawn  from  the  inner  side  of  the  head,  of 

'ibula  to  midway  between  the   two  mall. 
will  be  parallel  with  the  course  of  this  artery. 

PLAN  OF  RELATIONS. 
—Integument,  superficial  and  deen  fascia,  t'. 
ia,  extensor  longus  digitorum,  extensor  propriue  pollicie, 

anh  rior  tibial  nerve. 

ner  stefe.— Tibialis*  an  ticue,  extensor  pfropriug  pollicis. 

side. — Anterior  tibial  nerve,    extensor  longus    digi- 
n,  extensor  propriue  pofticis. 
id.— Interosseous  membrane,   tibia,  anterior  ligemcnt 
ie  joint. 

third  of  its  course   it  lies  between 
or  longus  digitor 
third,    between   the   tibialis   anti<  us 
propriue   pollicis;   and   in   the 
third,  betwc»  lendon  of  the   proprius 

•mennost  tendon- of  the  exi  - 
rum.     The  anterior  tibial   nerve  lie  a 
le;  then,  about  the  middle 
to  it;  and  in  the  lower 
•in  on  th  -!de. 

ecompanied   by  "two  v< 


288  ANTERIOR   TIBIAL   ARTERIES. 

venee  comites,  which  lie  upon  either  side  through 
out  the  whole  of  its  course. 

The  artery  may  be  tied  either   in  the   upper  or 
the  lower  part. 

Directions  for  the  operation  in  the  upper  Part.— Place 
the  patient  upon  his  back  and  extend  the  limb 
make  an  incision  about  four  inches  in  length  mid- 
way between  the  spine  of  the  tibia,  and  the  outer 
margin  of  the  fibula;  divide  the  fascia  and  in- 
termuscular septum  between  the  tibialis  anticus 
and  extensor  communis  digitorum,  placing  the 
foot  so  as  to  relax  these  muscles  and  separate  them 
from  eaci'  other  with  the  finger;  having  thui 
posed  th<  trtery,  separate  the  vena?,  comites  on 
either  si  ,  and  the  nerve  on  the  outer  side ;  isolate 
the  arte  and  pass  the  aneurismal  needle  under 
it  from  i  hout  inwards  so  as  to  avoid  the  anterior 
tibial  ik     e. 

Directions  for  the  operation  in  iht  middle   third 
the  Leg.— -Vlake  an  incisiou  about  three  inch 
length  al   ng  the    external   border   of  the  tibialis 
anticus  n    .scle  ;  slit  the  superficial   fascia  and  apo- 
neurosis J ".r  the  whole  length  of  the   wound  and 
divide  them  transversely  for  half  an  inch  or  more 
at  each  end  of  the  wound,  so  as  to  facilitate    the 
separation  at  the  muscles  ;  find  the  first  yellowish 
intermuscular   line    which    separates   the  tibialis 
anticus  and  the  extensor  communis  digitorum,  and 
open  it  thoroughly  with  the  finger  or  the  ^oint  of 
the  director ;  flex  the   foot   so   as   to   relax  these 
muscles,  and  then  hold  them  asunder  by  meai 
the  finger,  or  blunt  hooks;  draw  the  nerve  to  one 
side;  then  open  the  sheath,  and  isolate  the -artery 


ANTERIOR   TIBIAL   ARTERY.  289 

from  its  accompanying  veins,  and  pass  the  needlo 
under  the  art( 

Directions  for  ligation  of  the  artery  at  the  low<  r  third 
just  above  the  ankle  joint  -The  same  general  rules 
will  apply.  The  artery  is  very  superficial  and 
may  be  readily  de  alsations  between 

the  tend  ma  of  the  extensor  communis,  and  ex- 
tensor pollicis.  The  nerve  is  on  its  outer  side,  and 
should  ho  recognized  and  held  carefully  aside. 

The  anterior  artery  should  not  ! 
for  wounds.     The  point  of  election   is   the   middle 
third  of  the  limh,  as  it  is  more  readily  reached  and 
isolati  point     fn   the   upper   third    it   is 

covered  by  muscles,  and  cannot  b<  exposed  with- 
out disturbing  them  greatly.  In  the  \rd  of 
the  limb,  though  the  artery  is  superficial  and  can 
be  readily  found,  it  is  too  closely  in  relation  with 
the  sheaths  of  the  tendons,  and  the  ankle  joint  to 
justify  its  ligation  save  in  cases  of  absolute  ne 
T he  necessity  for  the  double  application 
of  the  ligature,  i.  e.  above  and  below  the  point 
of  division  ur  injury,  augments  in  p  u  to 
the  remoteness  of  the   artery   from    the    heart,    in 

intercommunication 
nastomosing  branches,  which  is  developed  as 
the  vi  edes  from  the  centre  of  the  tin 

tion. 

In  isolating  the  artery  advantage  will  be  ga 
by  curving  the   point  of  the   director.     Especial 
pains  should  beta  iparate  the  vepaa  comites 

so  as  to  avoid  the  induction  of  phlebitis. 

jatioi  of  the  Voralis  Pedis  Artery. — A  u  atony 
The  dornalisped  ontiuuation  of  the  ant< 


290  DORSAL   ARTERY. 

tibial  artery,  and  extends  from  the  bend  of  the 
ankle  to  the  back  part  of  the  first  interosseous 
space,  where  it  divides  into  two  brunches,  the 
dorsalis  hallucis  and  the  communicating. 

PLAN  OP  RELATIONS. 

In  front, — Integument  and  fascia,  innermost  tendon  of  the 
extensor  brevis  digitorum. 

Tibula  side. — Extensor  proprius  pollicis. 

Tibrila  side. — Extensor  longus  digitorum,  anterior  tibial 
nerve. 

Behind. — Astragalus,  scaphoid,  internal  cuneiform,  and 
their  ligaments,  and  the  anterior  tibial  nerve. 

It  is  accompanied  by  veme  comites  which  lie 
on  its  outer  side. 

Directions. — Make  an  incision  through  the  in- 
tegument two  inches  and  a  half  in  length,  on  the 
fibula  side  of  the  extensor  proprius  pollicis,  in  the 
interval  between  it  and  the  inner  border  of  the 
short  extensor  muscle;  divide  the  fascia  and  ex- 
pose the  artery;  separate  it  from  the  vena;  comites, 
and  anterior  tibial  nerve  on  the  outer  side,  and 
pass  the  aueurismal  needle  beneath  it  from  within 
outwards. 

This  is  a  simple  operation  and  may  be  perform* 
edin  cases  of  recent  wounds  or  of  hemorrhage  fol- 
lowing amputations  of  the  toes.  Care  should  be 
taken  not  to  malic  the  incision  farther  down  than 
the  back  part  of  the  first  interosseous  space  a 
artery  divides  at  that  point.  It  may  be  tied  at  any 
part  of  its  course,   but  the  i  ot   the   tarsal 

arch  is  the  point  usually    selected.  ■  Compression 
may  be  easily  effected  by   pr  against  the 

tarsal  bones,   and  this  should  always  be  fully  tried 


POSTERIOR   TIBIAL  291 

before  resorting  to  an  operation.  Occasionally  the 
Dorsalis  Pedis  is  developed  into  a  vessel  of  large 
size,  but  not  unfrequently  it  is  almost  entirely  de- 
ficient. When  it  does  not  send  terminal  brandies 
to  the  toes,  they  are  supplied  by  branches  from  the 
internal  plantar  artery.  Sometimes  the  place  is 
entirely    supplied    by    a  anterior   peroneal 

artery. 

Ligation  of  the  Posterior  Tibial  artery. — The  Pos- 
terior Tibial  is  larger  than  the  anterior  and  extends 
from  the  lower  border  of  the  popUteus  muscle,  to 
the  fossa  between  the  inner  ankle  and  heel,  where, 
beneath  the  origin  of  the  abductor  pollieis,  it  divides 
intotheinternal  and  external  plantar  arteries.  Atits 
origin  it  lies  opposite  the  interval  between  thefibula 
and  tibia;  as  it  descends,  it  approaches  the  inner 
side  of  the  leg,  lying  behind  the  tibia;  and  in  the 
lower  part  of  its  course,  it  is  situated  midway  be- 
tween the  inner  malleolus  and  the  tuberosity  of  the 
os-calcis. 

PLAN  OF  RELATIONS. 

In  front. —  Tibialis  posticus,  flexor  longus  digitorum,  tibia 
and  ankle  joint. 

Inner  side. — Posterior  tibial  nerve,  upper  third, 

Outcrsirfe. — Posterior  tibial  nerve,  lower  two  thi: 

■    eoleue,    deep  fascia   and    integu- 
ment. 

It  is  otfvered  bv  the  intermuscular  fascia,  which 

;i<(^ii  .  gastrocnemius   and 

soh-us:  ™i:  :•  third,  where  it  is  more 

su]    i  '  the   integument  and 

fascia,  and  i  ms  •  pith  the  inner  border  of 

tills.      J:  ipanied  by  two  veins, 


292  POSTERIOR   TIBIAL   NERVE. 

and  by  the  posterior  tibial  nerve  which  is  just  on 
the  inner  side  of  the  artery,  but   soon   crosses    it, 
and. is  on  its  outer  side  for  the  greater   portion    of  , 
its  course. 

^1/  the  ankle,  the  tendons  and  blood  vessels  are 
arranged  in  the  following  order :  First  the  tendons 
of  the  tibialis  posticus  and  flexor  longus  digitorum, 
lying  in  the  same  groove,  behind  the  inner  malleo- 
lus, the  former  beiug  the  more  internal.  Exter- 
nally is  the  posterior  tibial  artery,  having  a  vein 
on  either  side,  and  still  more  externally,  is  the 
posterior  tibial  nerve.  About  half  an  inch  nearer 
the  heel  is  the  tendon  of  the  flexor  longus  pollicis. 

Directions  for  the  application,  of  a  ligature  in  the 
upper  third. — Half  flex  the  leg  and  lay  it  upon- the 
inner  side;  make  an  incision  four  inches  in  extent 
beginning  at  a  point  f  to  1  inch  behind  the  inner 
edge  of  the  tibia,  and  running  parallel  with  that 
bone;  divide  the  superficial  fascia  and  aponeurosis, 
to  the  same  extent,  taking  care  to  avoid  the  saphena 
vein,  which  runs  up  nearly  in  the  direction  of  the 
cut;  make  an  incision  across  the  aponeurosis 
at  the  two  extremities  of  the  wound;  separate  the 
cellular  connexions  of  the  internal  head  of  the 
gastrocnemius,  on  the  anterior  surface,  with  the 
fore  linger  or  director,  and  draw  the  muscle  aside 
with  'e  blunt  hook;  divide  the  belly  of  the  soleus 
layer  hv  tayer  in  the  direction  of  the  .external 
wound,  and  at  the  distance  of  |  of  an  inch  from 
the  tibia;  cut  the  tendonous  fibres  of  thrs^  muscle 
on  the  grooved  director,  for  the  whole  length  of 
the  original  incision;  then  divide  the  deep  seated 
aponeurosis,  cautiously  and  in  the  same  manner; 


POSTERIOR    TIBIAL    ARTERY.  203 

open  the  sheath  of  the  artery,  isolate  the  vessel, 
and  pass  the  needle  below,  from  within  Outwards. 

Directions  for  the  application  bf  a  ligature  at  the 
rniddle  third  of  (he  leg. —  Place  the  Patient  as  before  ; 
make  an  incision  three  inches  long  obliquely  down- 
wards and  backwards  from  the  posterior  angle  of 
(lie  tibia  to  the  inner  border  of  the  tendo  Achillis, 
so  as  to  crpss  diagonally  over  the  intermuscular 
e  in  which  arc  lodged  the  vessels  ;  divide  the 
superficial  fascia  and  aponeurosis  in  the  same 
direction  ;  glide  the  forefinger  into  the  bottom  of 
the  wound,  and  under  the  tendo  Aehillis,  so  as  to 
detach  its  cellular  connexions  freely;  draw  the 
belly  of  the  soleus,  which  now  comes  in  view  up- 
wards and  backwards,  or  divide  it  if  necessary; 
puncture  the  deep  seated  aponeurosis,  insert  the 
tor  and  divide  carefully  ;  then  open  the  sheath 
bf  the  vessel,  isolate,  and  tie  the  artery. 

Dir  '  /•  the  application  of  a  ligature   to  the 

i  atthe  ankle  joint. — Place  the 
limb  as  before:  make  a  similunar. incision  through 
the  integument,  two  inches  and  a  half  in  length, 
midway  between  the  heel  and  the  inner  ankle; 
divide  the  subcutaneous  cellular  membrane,  and 
then  cat  through  the  internal  annular  ligament, 
cautiously  upon  the  grooved  director;  open  the 
sheath  of  the  ves  from  the  veUse 

comites,  isolate,  and  pass  the  needle  from  the  heel 
towards'the  ankle  in  order  to  avoid  the  posterior 
tibial  nerve,  care  being  taken  not  to  include  the 
vein 

r!''  application  of aligature  to  the  /'<>.  - 
lihial  arU  ry  in  the  low(  r  third  oftht  leg. — Place 


201  POSTERIOR  TIBIAL  ARTERY. 

tlie  Patient  as  before ;  make  an  incision  about 
three  inches  in  length,  parallel  with  the  inner 
margin  of  the  tendo  Achiilis;  carefully  avoid  the 
internal  saphena  vein,  and  divide  the  two  layers 
of  fascia  upon  a  grooved  director;  open  the  sheath, 
separate  the  artery  from  the  veil*  comites,  isolate, 
and  introduce  the  needle  so  as  to  avoid  the  nerve 
which  is  on  the  external  side. 

The  depth  of  the  artery  in  the  upper  and  middle 
thirds  renders  it  very  difficult  to  tie  the  vessel  at 
these  points,  and  it  is  only  justifiable  in  cases  of 
wounds  of  the  vessel. 

In  aneurismeal  tumours  of  the  middle  third,  it- 
is  better  to  ligate  the  femoral,  rather  than  to 
operate  in  these  localities. 

When  the  sole  of  the  foot  is  woanded  or  when 
obstinate  hemorrhage  follows  amputation  of  the 
toes,  &c,  the  artery  should  be  tied  either  at  the 
ankle  joint  or  in  the  lower  third  of  its  course. 

The  latter  steps  of  all  these  operations  may  be 
much  facilitated,  by  flexing  the  leg  upon  the  thigh 
and  extending  the  foot  so  as  to  relax  the  muscles. 

The  incision  must  be  made  from  above  down- 
wards when  the  right  leg  is  operated  on,  and 
from  below  upwards  where  the  ligature  is  applied 
to  the  left  limb. 

Guthrie  recommended  and  practised  ligation 
of  the  popliteal  artery  in  cases  of  wounds  compli- 
cated with  extensive  effusion  of  blood  between  the 
muscle  ;  but  it  would  be  far  better  to  tie  the  fem- 
oral under  such  circumstances. 

When  this  artery  is  tied  for  wounds,  no  regular 
operation  can  be  performed,  but  an  incision  of  suf- 


POS'J  ERIOP  TIBIAL    lRTBR"i  .  295 

ficienl  length  should  be  made  through  the  gaatrbc 
nemius  and  soleus,  taking  the  wound  for  its  ceu- 
tre.  Two  ligatures  must  invariably  be  applied  un- 
der these  circumstances,  the  one  above  and  the 
other  below  the  point  of  division,  so  as  to  prevent 
the  possibility  of  hemorrhage  either  from  the  car- 
diac orthe  distal  side  of  the  vessel. 

In  wounds  of  the  foot,  compression  should  be 
made  upon  the  artery,  at  a  point  about  a  finger's 
breadth  behind  the  inner  malleolus,  before  resort- 
ing to  an  operation.  Pressure  upon  this  point 
•on  becomes  very  painful,  and  should  not  be  per- 
sisted in. 

jation  of  /■<  Peroneal  Artery.-  -The  peroneal 
artery  rises  from  the  posterior  tibial,  about  an  inch 
below  the  popliteus  muscle,  and  terminates  upon 
the  outer  side  of  the  os-calcis.  It  rests  first  upon 
the  tibialis  posticus,  and  for  the  greater  part  of  its 
course  in  the  fibres  of  the  flexor  longus  pollicis,  in 
a  groove  between  the  interosseous  ligament  and  the 
'  bone.  It  is  covered  in  the  upper  part  of  its  course 
by  the  sole  as  [and  deep  fascia  ;  and  below  by  the 
flexor  longus  pollicis. 


PLA*  LATIONS. 

la  front. — Tibialis  posticus,  flexor  longus  pollicis. 

. — Fibula. 
Behind. — Soleus.  deep  fascia,  flexor  longus  pollicis. 

This  artery  rarely  requires  to  be  tied,  except  in 
cases  of  :ompound  fracture,  or  punctured  wounds, 
when  no  general  rules  can  be  followed.  It  is  too 
deeply  seat<  d  above,  and  too  small  below  for  an  op- 
eration, so  thai  it  is  only  in  its  middle  portion  that; 


296  PBRONEAL  ARTERY. 

a  ligature  is  applied.  This  artery  lies  between 
the  tendo  Achillis  and  the  fibula,  while  the  posteri- 
or tibial  is  on  the  opposite  side,  between  the  ten- 
do  achillis  and  the  internal  malleolus. 

For  statistical  information  in  regard  to  the  liga- 
tion of  arteries  in  the  city  of  Richmond,  refer  to  ta- 
ble "H"  of  appendix. 


C  H  A  P  T  E  R  VII. 


DISLOCATIONS. 

Lawrence  defines  dislocation  to  be  "a  perma- 
nent separation  of  one,  two,  or  more  bones  that  arc 
naturally  articnl  ed — a  separation  that  is  gener- 
ally produced  by  external  violence."  According  to 
this  definition  every  bone  in  tbe  body  is  liable  to 
this  accident,  yet  many  of  them  are  so  firmly  at- 
tached ns  to  preclude  the  possibility  of  such  a  re- 
sult save  by  the  employment  of  an  amount  of  force 
which  produces  other  effects  of  so  much  graver 
character  as  to  render  their  mere  separation  a 
matter  of  subordinate  consideration.  The  bones 
which  compose  the  skull,  for  instance,  hardly  ad- 
mit of  being  detached  the  one  from  the  other,  save 
by  a  degree  of  violence  which  produces  the  most 
Berious  consequences  to  themselves  and  the  subja- 
cent purls.  The  same  remark  applies  to  bones  of 
the  pelvis,  and,  in  fact,  to  all  bones,  connected  by 
plain  surfaces  almost  as  brOad  as  themselves,  such 

the  vertebrae,  the  tarsus  and  the  carpus. 

Far  the  greater  number  of  these  accidents  occur 
al  those  articulations  which  are  known   as  (he  gin- 


298  VARIETIES  OP  DISLOCATION. 

glymoid  or  hinge  like  joints,  unci  the  orbicular  or 
ball  and  socket  joints.!  The  former  arc  neither  so 
firmly  held  together  by  ligaments  nor  so  strongly 
supported  by  muscles,  and  hence,  their  separation 
is  a  matter  of  easy  accomplishment. 

The  orbicular,  for  the  same  reason,  require  less 
force  to  separate  them  than  the  ginglymoid  ;  thus 
dislocations  occur  with  more  ease  and  frequency  at 
the  shoulder  than  at  the  elbow,  at  the  hip  than 
at  the  knee,  and  so  on  for  other  similar  articula- 
tions. 


Varieties  of  Dislocation. — Dislocations  may 
be  complete,  incomplete,  spontaneous,  simple,  com- 
pound, complicated,  congenital,  recent,  ancient 
primitive  or  consecutive. 

Complete  Dislocation. — When  the  articular  sur- 
faces are  entirely  separated,  the  dislocation  is  said 
to  be  complete. 

Incomplete  Dislocation. — When  the  bones  are  on- 
ly partially  separated,  the  dislocation  is  said  to  be 
incomplete.  Practically,  there  is  not  a  great  deal 
known  concerning  this  variety  of  dislocation  atthe 
orbicular  joints  ;  but  instances  have  occurred  where 
the  head  of  the  humerus  was  found  on  the  edge  of 
the  glenoid  cavity.  In  the  hinge  like  joints,  asthe 
knee,  elbow,  and  ankle,  the  osseous  surfaces  com- 
monly remain  partially  in  contact. 

Sponta?ieous  D:slocation. — This  occurs  in  conse- 
quence of  disease.     When   the   ligaments   which 

I ' •  Much  more  depends  upon  the  relative   exposure   of  th«  joint," 
remarks  Hamilton,  •  than  upon  its  anatomical  structure." 


VARIETIES    OF   DISLOCATION.  299 

connect  the  bonds  are  altered  by  disease  of  the 
joint,  one  of  the  bones  may  be  thrown  out  of  posi- 
tion by  the  action  ol'  the  muscles,  the  ordinary 
cheeks  and  balances  being  removed — au  occurrence 
which  not  (infrequently  takes  place  at  the  Hip 
joint,  and  is  occasionally  seen  in  the  knee.  Some- 
times, in  children,  there  seems  to  be  an  entire  re- 
laxation both  of  the  muscles  and  ligaments  sur- 
rounding the  shoulder  joint,  and  spontaneous  dis- 
location occurs,  the  limb  falling  from  its  nor- 
mal position,  by  the  force  of  gravity  alone.  Tins 
is  a  grave  accident,  requiring  time,  patience,  and 
skill  to  secure  a  permanent  retention  of  the  parts 
in  their  natural  position. 

Sim/pie  Dislocation. — This  dislocation  is  called 
simple  when  unattended  by  fracture  of  the  hone. 
laceration  of  muscular  tissue,  injury  to  nerves. 
division  of  blood  vessels,  &c. 

Compound  Dislocation.  —  A  compound  dislocation 
LS  one  in  which  there  is  an  external  wound  connect- 
ing with  the  separated  parts.  The  skin  is  usually 
made  tense  by  the  presence  oi  a  portion  of  the 
bone  in  an  abnormal  position,  and  in  some  in- 
stances it  is  ruptured,  making  an  external  wound. 
through  which  the  osseous  structures  protrude  or 
not,  according  to  the  circumstances  of  the  case. 
When  this  rupture  occurs  a  compound  dislocation 
is  the  result. 

Complicated  Dislocation. — When  in  conjunction 
with  the  separation  of  the  bones,  there  occurs  frac- 
ture of  the  arti  ulating  surfaces,  muscular  lacera- 
tion, injury  of   important  nerves,  division  of  large 


300 


CAUSES   OF   DISLOCATION. 


arteries,  &c.,  the  dislocation  is  said  to  be  compli- 
cated- 

Congenital  Dislocation. — When  from  malforrna- 
tiou  of  the  articulation  the  hones  cannot  remain 
in  contact,  the  dislocation  is  styled  congenital. 

Recent  Dislocation. — A  luxation  which  has  taken 
place  within  a  period  of  a  few  days  or  at  least  a 
few  weeks  is  styled  "recent.  " 

Ancient  Dislocation. — 'A  luxation  which  has  ex- 
isted for  a  lunger  period  is  considered  an  "ancient 
dislocation,  "  though  the  exact  point  of  time  at 
which  it  ceases  to  he  "recent"  and  becomes  "an- 
cient" has  not  been  fully  determined. 

Primitive  Dislocation. — When  the  hone  remains 
nearly  or  precisely  in  the  position  into  which  it  lias 
been  first  thrown  by  the  force  brought  to  bear 
upon  it,  the  luxation  is  "primitive.''' 

Consecutive  Dislocation. — When  the  original  po- 
sition of  the  bone  has  been  changed,  in  consequence 
of  muscular  action,  attempts  at  reduction,  or  from 
any  other  cause,  the  luxation  is  called  "consecu- 
tive." Thus  a  "primitive"  dislocation  upon 
ischiatic  notch  may  become  a  "consecutive"  dis- 
location upon  the  dorsum-ilii  or  vice  versa. 

Causes  of  Dislocation.! — The  causes  which 
operate  in  the  production  of  dislocations  may  be 
divided  into  immediate  and  remote. 


I  Malgaigne  after  an  analysis  of  six  hundred  aud  forty  three 
of  dislocation,  states  that  "  hexations  are.  very  rare  in  "infancy,  and 
that  the  frequency  increases  gradually  up  to  the  fifteenth  year— then  , 
more  rapidly  up  to  the  sixty  fifth  year,  trom  which  period  onward 
they  become  more  rare."     The  deduction  from  this  statement  is  that 
age,  as  a" predisposing  cause,  is  most  active  in  middle  life,  lass 
ir  advanced  lift  and  ioast  active  in  early  life. 


CAUSES  OP   DISLOCATION.  301 

Immediate  causes  are  those  agencies  which  exer- 
cise a  direct  instrumentality  in  separating  the  .M'ti- 
eglatcd  bones.  Under  this  head  are  comprised 
external  violence,  muscular  contraction,  and  a  com- 
bination of  the  two. 

External  violence. — This  may  act  either  directly 
by  pulling  or  twisting  the  parts  asunder — as  when 
the  foot  is  displaced  by  a  turn  of  the  ankle,  w  hen 
the  thumb  is  dislocated  backward  by  a  blow,  or 
when  the  arm  is  torn  from  its  socket  by  machine- 
ry— or  indirect'.-/  when  the  force  acts  at  a  disi 
from  the  joint  and  the  bone  is  thrown  from  its 
socket  by  the  "lever  like  movement  of  the  shaft " — 
as  takes  place  when  the  head  of  the  humerus  is  dis- 
Iocated  by  a  fall. 

Muscular  action. — Muscular  action  may  cruse 
the  displacement  of  a  bone  even  when  the  parts 
ore  in  a  healthy  condition.  Thus  the  lower  jaw 
may  be  dislocated  by  excessive  gaping,  and  the 
humerus  driven  from  its  place  by  making  a  violent 
muscular  effort  as  in  throwing  a  stone,  strikil  -  a 
blow,  &c.  When  the  joint  has  been  weakened  by 
previous  disease,  dislocation  readily  results  from 
muscular  action  as  can  be  easily  "understood. 

Combination  of  external  violence  and  muscular 
action. — That  dislocation  may  be  occasioned  by  the 
combined  influence  of  these  two  causes,  when 
neither  would  be  sufficient  of  itself  to  produce 
such  a  result,  is  evident.  The  usual  manner, 
however,  in  which  these  two  agencis  act  together 
is  conjointly  but  not  contemporaneously.  Thus, 
in  dislocation  at  the  orbicular  joint,  after  the  head 
of  the  bone  has  been  thrown  out  of  the  cavity  by 
13 


302  SYMPTOMS    OF   DISLOCATION. 

external  violence,  it  is  still  farther  displaced  by 
the  action  of  the  muscles  which  surround  the  part. 
Remote  causes  are  those  influences  which,  by  re- 
laxing the  ligaments,  weakening  the  muscles, 
tering  the  articular  surfaces,  &c,  &c,  predispose 
the  parts  to  separate,  and  facilitate  the  action  of 
the  various  agencies  described  in  detail  in  the  pre- 
ceding paragraph.  An  abundant  secretion  of 
synovia,  even  when  no  organic  change  has  taken 
place  in  connexion  with  the  articulation,  belongs 
properly  to  the  catagory  now  under  consideration. 

Symptoms  of  Dislocation. — The  symptoms  or 
signs  by  which  dislocations  may  be  recognised  are ; 
paift;|  loss  of  symmetry ;  change  in  the  direction 
of  the  Hmb  ;  alteration  in  the  length  of  the  member ; 
preternatural  immobility:  swelling  of  the  surround- 
ing parts ;  and  loss  of  normal  function. 

It  may  be  distinguished  from  fracture  by  the 
absence  of  crepitus;  by  the  fixedness  of  the  mem- 
ber; and  by  the  failure  of  the  bones  to  separate 
after  having  been  properly  approximated.  Not- 
withstanding*, that  these  three  signs  constitute  the 
usual  distinction  between  dislocation  and  fracture, 
it  is  impossible  to  rely  exclusively  upon  any  one 
of  them  in  determining  the  diagnosis.  Each  may 
in  turn  associate  itself  with  either  accident,  and  it 
is  only  by  considering  them  together  as  whole, 
in  conjunction  with  other  circumstances,  that  a 
correct  opinion  may  be  formed  in  a  multitude  of 
cases. 

2  %  The  pain,  of  dislocation  is  more  intense  than  that  of  fractures  in 
«MMSe%ntHce  of  the  pressure  of  the  ends  of  the  bone  upon  the  nerves 


Treatment  of  dislocation.  303 

Treatment  of  Dislocation. — The  general  treat- 
ment of  dislocation  consists  in  : 

The  reduction  or  return  of  the  bones  to  their 
normal  relations. 

The  retention  of  the  bones  in  their  original  position. 

Reduction. — In  returning  the  bones  to  their 
original  relations,  the  Surgeon  has  four  great  ob- 
stacles to  contend  with  and  to  overcome,  viz : 

Muscular  contraction ;  the  anatomical  construc- 
tion of  the  joint ;  the  smallness  of  the  tear  in  the 
capsule  and  the  difficulty  of  finding  its  direction 
and  position — this  is  especially  true  of  the  hip 
joint; — and  the  development  ot  ligamentous  bands 
forming  new  but  powerful  attachments  between 
the  head  of  the  bone  and  the  surrounding  parts. 

The  first  obstacle  is  to  be  overcome  by  means  of 
what  is  known  as  manipulation ;  %  and  by  extension 
and  counter  extension; — aided  by  the  administra- 
tion of  Chloroform,  by  the  exhibition  of  nauseants 
and  depressants;  by  bleeding;  by  the  warm-bath; by 
the  subcutaneous  introduction  of  opium  or  some 
one  of  its  preparations,  particularly  the  salts  of 
morphia.  In  regard  to  the  latter  mode  of  reaching 
and  relaxing  muscular  tibre.  the  author  would 
state,  that  after  much  experience  and  many  care- 
fully conducted  experiments,  he  is  so  thoroughly 
convinced  ot  the  great  value  o\'  this  practice  gen- 
erally as  to  induce  him    to   recommend   it  in  the 


X  This  is  familiarly  known  a*  Raid's  method,  though  it  dates  us 
lar  back  as  Hippocrates,  and  was  successfully  practised  by  Wiseman 
in  167(5,  lor  certain  luxations  at  the  hip  joint.  So  far  as 'the  United 
State?  are  concerned,  to  Phytic  and  Nathan  Smith  the  credit  is  due 
of  introducing  this  method  of  treating  dislocations.  Reid  did  not 
make  his  report  until  the  year  1851,  some  forty  years  after  th«  suc- 
cessful experiment  of  the  above  named  Surgeons. 


304  TREATMENT   OF   DISLOCATION. 

most  unqualified  terms,  to  the  profession.  Under 
the  head  of  extension  and  counter  extension  are  in- 
cluded the  various  mechanical  contrivances  which 
are  employed  for  the  purpose  of  overcoming  mus- 
cular contraction  and  of  returning  the  bones  to 
their  original  position. 

"When  manipulation  has  failed,  extension  and 
counter  extension  may  be  made  with  the  hands  of 
the  Surgeon  or  his  assistants,  with  the  compound 
Pulleys,  with  the  simple  rope  Windlass,  with 
Jarvis'  adjuster,  and  with  such  other  similar  ap- 
pliances as  may  suggest  themselves  in  this  con- 
nexion. In  this  way  we  are  enabled  to  exert  much 
more  power  and  to  overcome  the  contraction  of 
the  muscles  by  steady  and  gradual  resistance,  but 
there  is  always  danger  of  doing  serious  injury  to 
the  soft  parts;  and  hence,  the  importance  of  using 
uo  more  force  than  is  absolutely  necessary  and  of 
proceeding  with  great  caution  and  circumspection. 

When  individual  dislocations  are  considered, 
the  proper  directions  for  using  of  these  various 
mechanical  contrivances  will  lie  explained  in  de- 
tail. 

The  general  rules  for  the  application  of  exten- 
sion may  be  thus  summed  up. 

1.  Protect  the  skin  by  means  of  a  wet  roller  be- 
fore applying  any  powerful  extending  force. 

2.  Apply  the  force  slowly,  gently  aud  continu- 
ously, carefully  avoiding  any  jerking  of  the  parts, 
lest  the  artery  be  severed,  the  muscles  excited  to 
still  stronger  contractions,  &c. 

3.  The  traction  should  be  made  in  the  axis  which . 
the  limb  has  acquired  by  its  change  of  position. 


[TREATMENT   0?   DISLOCATION.  306 

without  reference  to  its  normal  direction  or  the 
situation  of  the  articulation. 

4.  In  dislocations  at  the  hip  joint,  apply  the 
extending  force  to  the  femur, — the  bone  displaced; 
but  in  dislocations  at  the  shoulder  joint,  apply  the 
extending  force  to  the  fore-arm,  using  the  whole 
limb  as  a  lever. 

5.  Do  not  employ  the  Pulleys,  the  adjuster,  &c, 
until  an  effort  at  reduction  has  been  attempted  by 
making  traction  with  the  hands,  &c,  aided  by 
Chloroform  and  such  other. agents  as  tend  to  relax 
the  muscles. 

The  author  has  succeeded  in  relaxing  muscular 
contraction  of  an  obstinate  and  decided  character 
by  the  subcutaneous  injection  of  morphia  imme- 
diately over  the  track  of  those  muscles  offering 
most  resistence  to  the  return  of  the  bone  and  he 
therefore  recommends  this  procedure  as  an  invalu- 
able adjuvant  in  the  accomplishment  of  the  indica- 
tion in  question,  particularly  if  there  be  but  little 
tumefaction  about  the  parts,  and  only  a  slight  de 
velopment  of  adipose  tissue. 

The  second  obstacle  is  to  be  overcome  by  obtain- 
ing an  exact  knowledge  of  the  anatomical  structure 
of  the  joint,  and  using  such  mechanical  appliances 
as  may  be  n<  to  tilt  or  lift  the  head  of  the 

bone  over  any  projecting  and  opposing  eminence 
into  its  proper  cavity.  Some  times  this  is  effected 
by  using  the  limb  as  a  lever  df  various  degrees,  and 
then  again  by  the  direct  application  of  force  in 
such  awa  raise   the   limb   bodily  over  the 

obstruction,  relying  upon  muscular  contraction  to 
carry  it  into  its  normal  position.     This  subject  will 


306  TBEATMENT   OF   DISLOCATION. 

also  be  more   particularly   dwelt   upon   under  the 
next  section  of  this  work. 

The  third  obstacle  is  to  be  met  and  disposed  of 
by  endeavouring  to  find  the.  particular  locality  of 
the  tear,  and  ascertaining  the  direction  and  posi- 
tion in  which  the  dislocated  head  corresponds  to 
the  hole  in  the  capsule.  The  dislocated  head  does 
not  always  preserve  the  original  position  in  which 
the  luxating  force  places  it,  but  by  means  of  an 
abduction,  flexion,  &c,  which  subsequently  follows, 
is  forced  into  a  new  position.  Alt  attempts  at  re- 
duction must  therefore  be  commenced  by  restoring  the 
dislocated  bone  to  its  primitive  position,  and  causing  i 
to  glide  from  that  into  its  normal  situation.  These 
observations,  of  course,  apply  only  to  ball  and  socket 
joint,  and  have  a  particular  reference,  to  disloca- 
tions of  the  hip. 

The  fourth  difficulty  is  to  be  surmounted  by 
operating  before  the  new  attachments  have  formed, 
or  rather  before  they  have  become  thoroughly  or- 
ganized. 

The  period  beyond  which  reduction  should  not 
be  attempted  varies  according  to  the  nature  of  the 
dislocation  and  the  concomitant  circumstances.  It 
may  be  practised  at  a  much  later  day  in  luxations 
of  the  orbicular  than  of  the  giuglymoid  joints  and 
this  remark  applies  particularly  to  those  at  the 
shoulder,  as  all  experience  demonstrates.  Sir  A. 
Cooper  declares,  emphatically,  that  "the  latest 
period  at  which  reduction  can  be  safely  effected, 
even  in  this  dislocation,  does  not  exceed  '•  three 
months;  while  for  the  hip  tight  weeks  is  the  proper 
limit."     It  is  undoutedly  true,  that  these  disjoca- 


TREATMENT  OF  DISLOCATION.  307 

tion3  have  been  reduced,  with  entire  safety  1  .he 
patients ;  but  these  are  the  exceptions  rathe-  .nan 
the  rule,  and  should  be  so  regarded  by  the  Surgeon. 

Retention. — When  the  bone  has  been  returned  to 

normal  situation,  it  must  be  retained  there  by 
proper  splints  and  bandages,  and  rest  enjoined,  at 
least  for  several  days. 

If  symptoms  of  inflammation  show  themselves, 
they  should  be  arrested  by  the  prompt  and  persis- 
tent application  of  cold  water. 

In  dislocation,  it  shrjuld  be  remembered, that  the 
principal  indications  as  well  as  the  chief  difficulty 
consists  in  reduction,  that  is,  restoring  the  parts  to 
their  natural  status;  while  on  the  other  hand,  in 
fracture,  the  most  important  desideratum  is  to  em- 
ploy means  to  retain  the  parts  in  apposition,  after 
they  have  been  reduced. 

The  above  rules  hold  good  for  the  treatment  of 
simple  dislocation. 

Treatment  of  Compound  Dislocations?. — These  are 
very  serious  injuries,  owing  to  the  peculiar  suscep* 
tibility  of  the  parts  which  enter  into  the  formation 
of  joints,  to  take  an  inflammatory  action^  There 
is  usually  little  or  no  difficulty  in  reducing  the  dis- 
location, or  in  retaining  the  bones  in  position ;  but 
the  great  danger  is  in  the  subsequent  infLammatiom 
suppuration,  &c,  which  are  likely  to  ensue.  If 
there  be  a  reasonable  probability  of  securing  union 
by  the  first  intention,  the  parts  should  be  brought 

gether  and  cold  water  dressings   employed  ;  but 
on  the  other  hand,  if  the  joint  be  large,  and  there 
b  much  laceration  of  the  soft  parts,  the  limb  should 
be  amputated. 


.308  TREATMENT  OP  DISLOCATION. 

Wounds  of  this  character  are  more  favorable  when 
occurring  in  their  upper  than  the  lower  extremity 
for  reasons  already  given  at  length  in  another  por- 
tion of  this  work* 

Ireatmentof  Complicated  Dislocations. — Should  be 
treated  on  the  same   principles,   precisely   as  the 

st.  Indeed  the  two  so  frequently  occurr  contem- 
poraneously that  it  is  unnecessary  to  establish  dif- 
ferent rules  for  their  management.  If  the  bony 
parts  immediately  involved  are  fractured,  resection 
nay  be  successfully  practised  unless  the  soft  parts 
are  too  much  injured,  when  amputation  must  be 
speedily  resorted  to.  as  the  only  means  of  preserv- 
ing life. 

When  fracture  of  the  shaft  of  a  bone  is  complica- 
ted with  dislocation  of  its  head,  great  difficulties 
will  necessarily  present  themselves  in  the  way  of 
a  proper  reduction.  It  is  much  safer  to  reduce  the 
dislocation  without  waiting  for  the  bone  to  unite 
as  the  period  required  for  this  process,  would  car- 
ry the  surgeon  far  beyond  the  time  when  reduction 
is  esteemed  a  practicable  measure.  The  fractured 
limb  must  be  put  up  very  carefully  in  wooden 
splints,  before  extension  is  made. 

Particular  Dislocations. — Dislocation  of  the 
lower  Jaw. — The  inferior  maxillary  bone  may  be 
either  completely  or  partially  dislocated.  When 
completely  dislocated,  both  condyles  slip  beyond 
the  eminenthearticularisinto  the  zygomatic  fossa, 
while  the  coronoid  process  hitches  against  the 
malar  bone  and  the  axis  of  the  same  is  directed 
obliquely  forwards.    When  the  bone  is  partially 


DISLOCATION  OF  LOWER  JAW.  300 

dislocated,  one  condyle  remains  in  position  while 
the  other  is  carried  forwards  into  the  zygomatic 
fossa. 

A  sub-luxation  is  also  described  by  Sir  Ashly 
Cooper,  which  is  most  frequently  met  with  in 
young;  and  delicate  women,  in  which  the  head  of 
the  bone  appears  to  slip  before  the  internal  articular 
cartilage,  so  as  to  prevent  the  closure  of  of  the 
mouth. 

Causes. — Sometimes  this  dislocation  is  caused  by 
direct  violence, — as  by  blows,  kicks,  falls,  &c. 
Again,  in  gaping,  yawning  and  laughing,  the  mus- 
cles are  put  too  violently  upon  the  stretch  and  the 
condyle  is  carried  beyond  the  glenoid  cavity.  The 
jaw  has  also  been  dislocated  in  attempts  made  to 
draw  teeth,  by  a  sudden  action  of  the  hand,  depres- 
sing the  chin  to  too  great  an  extent. 

An  imperfect  dislocation  of  the  jaw  is  sometimes 
occasioned  by  a  relaxation  of  the  ligaments  sur- 
rounding the  joint. 

Symptoms. — In  partial  dislocation  the  mouth  is 
not  so  widely  open  as  in  complete  dislocation,  but 
the  patient  cannot  close  it  in  consequence  of  the 
condyloid  process  being  carried  against  the  zygo- 
ma. The  chin  is  carried  to  the  opposite  side  ;  the 
incisor  teeth  are  advanced  upon  the  upper  jaw- 
saliva  is  somewhat  increased  in  quantity;  and  ar- 
ticulation is  difficult. 

In  complete  dislocation  the  mouth  is  widely  op- 
ened and  cannot  be  closed  ;  deglutition  and  speech 
are  much  impaired  ;  the  chin  is  lengthend;  the  sa- 
liva dribbles  over  the  lips  in  consequence  of  press, 
ure  on  the  parotid  glands;  the  cheeks  are  flattened; 
13b 


310  DISLOCATION  OP  LOWER  JAW. 

the  lower  line  of  teeth  are  advanced  beyond  the 
upper;  and  there  is  a  depression  in  front  of  the 
meatus,  and  a  prominence  in  the  temporal  fossa 
between  the  eye  and  the  ear. 
;  Treatment. — Stand  before  the  patient  and  apply 
the  thumbs  well  protected  to  the  molar  teeth  on 
either  side;  and  then  depress  the  angle  of  the  jaw 
forcibly,  and  at  the  same  time  raise  the  chin  by 
means  of  the  fingers  passed  under  it.  When  only 
one  side  is  luxated,  the  efforts  at.  reduction  should 
be  confined  to  that  side  alone  li\  subluxation, 
constitutional  remedies,  such  as  iron,  valerian,  & 2., 
should  be  administered,  and  repeated  blisters  ap. 
plied  directly  over  the  joint. 

Should  the  ordinary  means  fail  of  their  object, 
the  following  plan  may  be  resorted  to  :  Place  some 
hard  substance,  as  the  handle  of  a  spatula,  a  piece 
of  wood  or  ivory,  between  the  molar  teeth  or  the 
upper  and  lower  gum,  on  either  side,  or  transverse- 
ly from  one  to  the  other;  step  behind  the  patient, 
and  pass  the  hands  forward  under  the  chin  ;  push 
the  chin  up  forcibly,  so  that  by  means  of  the  wood 
between  the  teeth,  as  &  fulcrum,  and  the  bone  itself 
as  a  lever,  the  head  may  be  prized  out  of  its  new 
socket,  and  carried  by  the  muscles  over  the  eminen- 
tia  articularis  into  the  glenoid  cavity. 

The  four-tailed  bandage  may  then  be  applied, 
and  the  patient  made  to  refrain  from  talking,  eat- 
ing solid  food,  laughing,  &c.  Very  old  disloca- 
tions may  be  reduced  by  the  process  last  des- 
cribed. 

Dislocations  of  the  clavicle.— The  clavicle  may  be 
dislocated  at  either  of  its  extremities,   that  is,   at 


DISLOCATIONS  OF  CLAVICLE,  311 

its  eternal  or  acromial  end,  but  this  accident  is  rare 
compared  with  that  of  fracture  of  the  hone,  be- 
cause of  the  strength  of  its  ligamentous  attach- 
ments. 

Tne  eternal  end  may  be  luxated  either  fa-wards, 
backwards,  or  upwards,  being  thrown  before,  behind, 
or  above  the  sternum. 

The  acromial  end  may  be  dislocated  and   placed 
upon  the  upper  surface  of  the  acromion,   upon   tho 
-'or  part  of  the   tpine  of  the  scapula,  under  the 
acromion  and  beneath  the  coracoid  process. 

Symptoms. — As  the  clavicle  is  very  superficial, 
the  changes  of  conformation  which  accompanies 
these  various  dislocations  are  so  obvious  .  j  to 
render  a  recognition  of  the  accident  a  matter  of 
great  facility.  The  head,  of  the  bone  can  be  dis- 
tinctly felt  in  each  of  the  dislocations  referr  to, 
making  its  diagnosis  easy  and  certain. 
^Causes. — External  violence, — as  blows,  kici  fee. 
iment. — Reduction  is  easy  but  retention  iffi- 
cult,  because  the  accident  cannot  occur  withe  \  the 
rupture  of  the  strong  ligaments  which  ordinarily 
ho  id  it  in  position. 

Treatment  of  dislocations  of  the  sternal  end. — The 
dislocation  forwards  is  to  be  reduced  by  pushing 
the  ohoulder  outwards  and  bending  it  backwards, 
and  the  parts  retained  in  position  by  means  of  a 
pad  and  a  figure  of  8  bandage  applied  firmly  over 
lisplaced  end  of  the  bone — strips  of  adhesive 
er  may  be  substituted  with  advantage  for  the 

■  dislocation   upwards  is  of  extremely  rare 
occurrence,  but  when  ascertained,  should  be  treated 


312  DISLOCATIONS   OF   CLAVICLE. 

by  means  of  a  bandage  and  pad,  together  with  the 
elevation  of  the  elbow. 

The  dislocation  backwards  is  not  of  common 
occurrence,  though  there  are  quite  a  number  of 
cases  on  record.  It  generally  results  from  the 
point  of  the  shoulder  having  been  driven  upwards; 
or  by  the  hand  being  drawn  violently  forwards; 
or  by  the  direct  pressure  of  the  clavicle  backwards. 
The  treatment  consists  in  making  a  fulcrum  of  the 
fist  or  knee  in  the  axilla,  and  then  bringing  the 
elbow  well  to  the  side.  In  this  way  the  dislocation 
is  reduced  with  facility.  Retention  is  difficult,  and 
must  be  accomplished  by  the  figure  of  8  bandage 
tightly  applied  to  the  shoulders,  and  crossed  over 
a  large  pad  placed  in  the  middle  of  the  back,  the 
elbow  being  at  the  same  time  fixed  to  the  side. 
Adhesive  straps  may  be  substituted  for  the  ordinary 
bandage  as  they  adhere  to  the  skin  and  remain 
much  more  permanently  in  position. 

Treatment  of  luxations  of  the,  Acromial  end.— The 
dislocation  of  the  head  of  the  bone  upon  the  uppet 
surface  of  the  acromion  can  be  recognized  and 
reduced  easily  by  manipulation.  The  shoulder 
should  be  pushed  upwards,  outwards,  and  backwards, 
and  held  in  that  position  by  the  same  means  as 
those  employed  for  fracture  of  the  clavicle, — all  of 
whic  will  be  fully  described  under  the  head  of 
fraet  s,  &c.  Adhesive  straps  passed  from  the 
she.  'r  to  the  elbow,  embracing  the  arm,  are 
admi  >le  substitutes  for  other  and  more  compli- 
cate rangenients.  It  may  be  well  also  to  place 
a  pacl     .  the  axilla  and  to  bind  the  arm  to  the  side. 

Diei  >cation  under  the  Acromion. — ISTelaton  states 


DISLOCATION   OF  SIIOULDER.  313 

that  there  are  only  three  cases  of  this  luxation  on 
record.  It  certainly  is  of  very  rare  occurrence. 
The  treatment  is  precisely  the  same  as  for  fracture 
of  the  clavicle. 

Dislocation  beneath  the  coracoid  process  simply 
requires  the  clavicular  bandage. 

Dislocations  at  the  Shoulder  Joint. — The  humerus 
may  be  dislocated  in  four  directions,  viz:  down- 
wards in  the  axilla;  forwards  under  the  clavicle; 
backwards  upon  the  scapula. 

Dislocation  downwards. — This  dislocation  is  of 
most  frequent  occurrence. 

Causes. — Falls  upon  the  top  of  the  shoulder; 
blows  upon  the  shoulder;  violent  abduction  of  the 
arm  ;  &c. 

Symptoms. — The  Acromion  projects;  the  rotun- 
lity-  o\'  the  shoulder  is  lost;  a  round  body  can  bo 
Cell  in  the  axilla;  the  arm  is  lengthened,  numbed, 
and  carried  out  from  the  body  three  or  four  inches 
the  hand  cannot  be  placed  upon  the  opposite  shoulder 
while  the  elbow  touches  the  thorax;  there  is  great 
pain  when  the  elbow  is  forced  against  the  side. 

Treatment. — Reduction  is  accomplished  either 
by  manipulation  or  by  the  employment  offeree. 

Manipulation. — Administer  Chloroform  ;  carry 
the  elbow  about  45°  from  the  side;  flex  the  fore- 
arm at  a  right  angle  with  the  arm  so  that  the  palm 
of  the  hand  presents  to  the  patient's  abdomen* 
then,  using  the  forearm  as  a  lever,  rotate  the  head 
of  the  humerus  forwards  and  upwards  by  making 
the  hand  describe  a  semi-circle  from  before  back- 
wards until  the  palm  of  the  hand  looks  up,  the 
elbow  being  kept  oil  from  the  side;   holding  fju> 


314  DISLOCATIONS    OF   SHOULDER. 

forearm  in  its  semi-flexed  position,  with  the  palm 
of  the  hand  looking  to  the  operator,  carry  the 
elbow  gently  into  the  side;  then  quickly  rotate  the 
head  backward  and  upwards  by  reversing  the  mo- 
tion of  the  forearm  so  as  to  cause  the  hand  to  de- 
scribe an  entire  circle. 

In  the  anterior  and  posterior  dislocations  carry 
the  arm  as  nearly  perpendicularly  upwards  as 
possible,  or  in  such  a  position  as  will  throw  the 
head  of  the  bone  into  the  axilla,  and  then  proceed 
as  before. 

During  the  operation  the  scapula  should  be  firm- 
ly fixed  and  firmly  held  by  reliable  assistants. 

Employment  of  force. — The  dislocation  may  be 
reduced,  when  manipulation  has  failed,  by  means 
of  the  heel  in  the  axilla;  by  means  of  the  knee; 
by  means  of  Pulleys;  by  Jarvis'  adjuster,  &c. 

By  the  heel  placed  in  the  axilla. — This  is  th6 
oldest  and  most  convenient  process,  and  will  answer 
for  a  majority  of  recent  dislocations. 

Directions. — Place  the  patient  upon  his  back; 
administer  Chloroform  or  Ether  freely  ;  seat  your- 
self along  side,  and  place  the  foot  in  the  axilla; 
take  hold  of  the  wrist,  and  fix  one  foot  firmly  on 
the  ground;  then  draw  the  limb  steadily  down- 
wards ;  and  when  the  head  of  the  humerus  is  dis- 
engaged, and  drawn  out  of  its  new  bed,  carry  the 
hand  across  the  patient's  body,  employing  the  foot 
as  a  fulcrum  to  turn  the  bone  into  its  proper  situa- 
tion. Additional  force  may  be  employed  by  fasten- 
ing a  bandage  around  the  arm  and  carrying  it  over 
the  shoulders  of  the  Surgeon,  so  that  the  weight  of 
the  body  may  be  used  also  as  an  extending  force. 


DISLOCATIONS   OP    SHOULDER.  315 

If  this  be  not  sufficient,  still  greater  power  may  be 
gained  by  passing  a  towel  under  the  axilla,  and 
making  an  assistant  pull  upwards  and  backwards 
while  the  extending  force  is  applied  as  just  describ- 
ed. 

Process  with  the  knee. — This  is  precisely  the 
ame  in  principle  as  the  last. 
Directions. — Seat  the  patient  in  the  chair;  take 
a  stand  by  his  side,  rest  one  foot  upon  the  chair, 
and  place  the  knee  in  the  axilla  ;  then  seize  the 
arm  i  bout  the  elbow  with  the  right  hand;  steady- 
ing the  acromion  with  the  left,  and  draw  the  limb 
forcibly  downwards;  and,  when  the  head  has  been 
disengaged,  carry  the  arm  inwards  across  the 
patients  body. 

Process  by  the  Pulleys. — If  the  muscles  contract 
vig  or  the  dislocation  be  of  long  standing, 

so  that  it  does  not  yield  to  the  various  processes 
described  above,  it  may  become  necessary  to  use  still 
additional  force  and  the  Pulleys  may  be  employed. 
Directions. — Place  the  patient  in  a  firm  chair; 
fold  a  table  cloth  or  sheet  to  the  breadth  of  eight 
or  ten  inches,  and  place  it  around  the  chest  so  that 
its  middle  portion  is  applied  to  the  axilla,  and 
attach  its  ends  to  some  fixed  point  in  the  floor  or 
wall ;  pass  a  wet.  roller  round  the  arm  just  above 
the  elbow,  and  upon  this  fasten  either  a  strong 
worsted  tape,  by  means  of  a  clove-hitch,  or  a  towel 
properly  adjust    I  to    excoriate  as   little   as 

possible:  and  to  this  hitch  a  towel,  apply  the  ex- 
tending force,  and  make  firm  but  steady  traction. 
While  this  is  being  done  by  assistants,  stand  on 
the   outside  of  the  arm.   keep  it  bent,,  and  rotate 


316  DISLOCATIONS  OF  SHOULDER. 

the  humerus  on  its  own  axis  as  much  as  possible. 
Sometimes  by  placing  the  knee  in  the  arm  pit,  the 
redaction  will  be  much  facilitated. 

The  treatment  after  reduction  is  simple.  Brace 
the  arm  by  the  side  of  the  body,  either  by  long 
strips  of  adhesive  plaster,  or  the  roller  bandage 
and  support  the  forearm  and  hand  in  a  sling.  Con- 
tinue this  until  the  tear  in  the  capsular  ligament 
has  united,  and  the  muscular  tissues  have  returned 
to  their  normal  condition  of  quiesence. 

Compound  and  complicated  dislocations  should  be 
treated  upon  the  principles  already  established  in  the 
section  which  treats  of  dislocation  in  general. 

Dislocation  forward  under  the  clavicle. —  Causes. 
The  causes  are  the  same  as  for  the  last  dislocation, 
except  that  the  direction  of  the  impulse  slightly 
varies.  In  many  instances  this  is  consecutive  upon 
a  dislocation  into  the  axilla. 

Symptoms. — There  is  a  depression  under  the  outer 
end  of  the  acromion  ;  the  elbow  is  separated  from 
the  bod}^  and  carried  a  little  backward  ;  the  axis  of 
the  arm  is  thrown  inwards  towards  the  middle  of 
the  clavicle  ;  the  head  of  the  bone  may  be  felt 
under  the  clavicle ;  the  hand  cannot  be  placed  upon 
the  opposite  shoulder  while  the  elbow  remains  in 
contact  with  the  chest ;  and  there  is  pain  or 
numbness. 

Treatment. — The  treatment  is  the  same  as  for 
the  last  dislocation,  save  that  the  extension  'to 
be  made  at  first  somewhat  in  a  line  backwards  from 
the  body  until  the  head  of  the  bone  has  escaped 
beneath  the  coracoid  process  ;  the  extension  must 
be  made  downwards  and  outwards.     Subsequently 


DISLLOCATIONB  OF  SHOULDER.  317 

pull  downwards  or  even  upwards,  and  press  the 
head  of  the  bone  into  its  soeket.  Retain  as  before. 
Dislocation  backwards  upon  the  scapula.  This 
form  of  dislocation  is  seldom  met  with. 

Causes. — Falls  and  muscular  exertion,  with  the 
arm  in  a  position  exactly  the  reverse  of  the  last. 

Symptoms, — There  is  a  projection  under  the  spine 
of  the  scapula  ;  and  a  corresponding  depression 
under  the  acromion;  there  is  a  wide  space  between  the 
head  of  the  bone  and  thecoracoid  process;  the  ax 
is  of  the  shaft  is  directed  upwards  and  outwards 
the  arm  is  in  contact  with  the  body  and  carried 
across  the  chest  ;  the  humerus  is  rotated  inwards; 
and  the  hand  cannot  )>e  placed  upon  the  opposite 
Bhoulder. 

Treatment. — Sir  Astley  Cooper  recommends 
the  same  plan  of  treatment  with  pulleys,  &c,  as  in 
the  downward  dislocation,  and  that  the  extension 
should  he  made  downwards  and  outwards.  Vidal 
de  Cassis  insists  that  extension  shall  be  made  in 
the  direction  in  which  the  limb  is  found  :  and  in 
this  he  is  sustained  by  a  majority  of  those  who 
have  had  the  accident  to  manage.  Try  citherplan. 
or  both  in  turn.  Inn  take  especial  care  to  fix -the 
scapula.  The  bole-  is  retained  in  place  by  placing 
a  compress  against  th'e  head  of  the  humerus  and 
beneath  the  spine  of  the  scapula,  and  retaining 
them  in  position  by  means  of  a  roller  bandage. 

ther  partial  dislocations  of  the  hum- 
for  an  account  of  which  the  reader  is  referred 
to  standard  works  on  the  subject. 

Dislocations  at  tin   Elbow  Joint. — Numerous  luxa- 
tions ojcur  at  this  joint,  viz  :  dislocation  of  the  ra 


318  DISLOCATIONS  OF  ELBOW. 

dius  and  ulna  backwards;  dislocation  of  radius  and 
ulna  forwards  ;  dislocation  of  both  bones  laterally; 
dislocation  of  the  ulna  backwards  ;  dislocation  of 
radius  forwards ;  dislocation  of  radius  backwards  ; 
and  dislocation  of  radius  outwaads. 

Dislocation  of  Ulna  and  Radius  backwards. — 
This  accident  is  plainly  marked  by  the  change  in$ 
the  form  of  the  joint,  and  by  its  great  loss)  of  mo-* 
tion.  There  is  a  considerable  projection  posteriorly; 
on  each  side  of  the  olecranon  there  is  a  depression; 
the  articulating  end  of  the  humerus  can  be  felt  in 
front ;  the  hand  and  fore  arm  are  in  a  state  of  su* 
piuation,  and  cannot  be  pronated ;  and  the  fore 
arm  is  slightly  flexed  on  the  arm.  The  coronoid 
process  is  frequently  broken,  and  if  so,  may  be 
felt  loose  in  front  of  the  joint ;  but  if  not,  it  will  be 
found  fixed  against  the  posterior  surface  of  the  hu- 
merus. 

Ireatmeni. — This  dislocation  ma}'  be  reduced 
thus :  seat  the  patient ;  take  hold  of  his  wrist,  and 
place  your  knee  on  the  inner  side  of  the  elbow 
joint ;  bend  the  fore  aim  and  press  upon  the  radi 
us  and  ulna  firmly  with  the  knee,  so  as  to  separate 
them  from  the  humerus,  and  to  remove  the  coro: 
noid  process  from  the  posterior  fossa  of  that  bone ; 
while  this  is  being  done,  gradually  flex  the  for< 
arm,  and  the  bones  will  slip  into  their  respective 
sockets. 

Apply  a  bandage,  keep  the  arm  in  a  flexed  posi- 
tion, use  cold  lotions,  and  support  the  limb  with  a 
sling.  When  the  coronoid  piocess  is  broken,  keep 
it  firmly  in  its  place  by  means  of  a  compress  and 
adhesive  straps. 


DISLOCATIONS  OF  ELBOW.  319 

This  accident  is  usually  caused  by  an  attempt 
to  catch,  on  the  imperfectly  extended  arm,  while 
falling". 

Dislocation  of  both  Bones  forward. — It  is  almost 
impossible  for  this  accident  to  occur  without  a 
fracture  of  the  olecranon  process:  though  it  may 
do  so  in  rare  cases.  It  may  be  recognized  by  the 
elongation  of  the  fore  arm;  the  projection  of  the 
condyles  of  the  humerus  ;  the  depression  of  the 
posterior  surface  of  that  bone:  and,  when  the  ole- 
cranon is  broken  off  by  the  presence  of  that  pro- 
cess behind,  and  the  great  mobility  of  the  fore 
arm. 

Treatment. — The  same  process  is  to  be  followed 
as  in  the  last  case,  only  the  foree  used  must  be 
greater.  Put  the  arm  up  in  firm  angular  splints, 
keep  the  hand  semi-pronated,  apply  cold  lotions, 
and  use  the  sling. 

Dislocation  of  both  Bones  laterally. — This  dislo- 

•  ion  may  occur  on  either  side,  but  generally  is 
an  incomplete  one,  either  the  radiushitches  against 
the  internal  condyle,  or  the  ulna  against  the  ex- 
nal,  and  prevents  an  entire  separation  ol'  the 
articular  surfaces.  This  may  be  recognized  by  the 
peculiar  deformity ;  lossof  motion  :  the  movements 
oftheradiu  the  hand  when  the  arm  is  rota- 

ted ;  the  position  of  the  ulnar  either  on    the  inner 
mdyle;  the  radius  forming  a   protuber- 
nd  on  the  outer  Bide  ofthc  humerus; 
bj  of  the  condyle  ;  and  by  the 

hollow  above  thi 

Tin  the  dislocation  by  bending 

the  arm    powerfully  over    the  knee   and    making 


320  DISLOCATIONS  OF  ELBOW. 

traction  at  the  wrist.  As  soon  as  the  radius  and 
ulna  are  separated  from  the  humerus,  the  biceps 
and  brachialis  pull  the  bones  into  their  proper  po- 
sitions. 

Retain  the  parts  insitu  by  the  angular  splints I 
supf  ort  the  arm  with  a  pad  ;  and  keep  the  limit 
quiescent.  Nelaton  declares  that  he  has  seen  but! 
one  case  of  this  variety  of  dislocation. 

Dislocation  of  the  Ulna  Backwards.— This  is  the 
only  displacement  to  which  the  ulna  alone  is  subS 
ject;  and  this, seldom  presents  itself  without  more 
or  less  dislocation  of  the  head  of  the  radius.  It  may 
be  distinguished  by  the  great  deformity  of  the 
member,— the  olecranon  being  thrown  backwards,' 
and  the  fore  arm  and  hand  very  much  twisted  inj 
wards. 

The  radius  remains  in  its  norma!  position,  and 
its  movements  under  the  hand  can  be  easily  recog. 
nized  when  the  limb  is  rotated.  The  coronoid  Is 
frequently  fractured  in  this  accident,  and  crepitates 
when  moved.  If  this  be  the  case,  the  dislocation 
can  be  reduced  and  produced  at  pleasure. 

It  is  also  impossible  to  extend  the  arm  or  to 
bend  it  at  right  angles,  in  uncomplicated  cases  of 
this  injury. 

Treatment.—  Reduction  is  effected  precisely  as  in 
the  last  accident,  described.     The    Radius,  act 
a  lever  under  these  circumstances,    and  aids    the 
muscles  in  bringing  the  bone  into  position. 

Retentiou  may  be  accomplished  by  the  use  ut  the. 
appliances,  &Ci,  described  above. 

Dislocation  of  the  Radius  forwards.— This  i 
most  unusual  accident,     It  may  occur  however, 


DISLOCATIONS   OF    ELBOW.  321 

|he  result  of  a  fall  on  the  palm  of  the  hand,  by 
which  the  lower  end  of  the  bone  is  pushed  back- 
wards, and  its  upper  extremity  carried  forwards, 
rapturing  the  annular  ligament,  and  throwing  its 
lead  against  the  external  condyle,  [t  may  be  dis- ' 
wnguished  by  the  following  signs,  viz.:  the  for 
is  slightly  bent,  and  can  neither  be  extended  nor 
bron.irlit  at  a  right  angle  with  the  arm;  the  hand  is 
fixed  midway  between  pronation  and  supination, 
Rough  neither  motion  can  be  perfected;  on  relation, 
the  bone  can  be  distinctly  felt,  and,  the  pain  is  very 
great;  the  whole  of  the  nppe"  side  of  llm  arm  is 
carried  somewhat  upwards,  producing  great  de- 
formity; and  the  constant  disposition  of  the  head 
if  the  radius  to  slip  out  of  place  because  of  the 
rupture  of  the  annular  ligament. 

Treatment. — Reduce  by  applying  extension  after 
[having  firmly  fixed  the  upper  arm,  and  then  bend- 
ing the  arm  and  pushing  the  head  into  its  place. 

Retain  by  applying  a  pad  immediately  over  the 
head  of  the  radius,  binding  it  firmly  by  means  oi' 
jdhesive  strips,  and  keep  the  forearm  well  Hexed. 

Dislocation  of  radius  backwards. — This  may  hi' 
Known  by  the  head  of  the  bone  being  felt  subcii- 
mneoustybehindtheexln'nalcondyka.nd  by  the  move- 
the  elbow  being  limited   and  extremely 

fcinful. 

atment. — Reduoeby  bending  the  forearm,  and 
making  traction. 

.  Retained  by  keeping  the  arm  tlexed.  Sir,  A. 
Cooper  declared  that  he  had  never  seen  a  ease  of 
this  particular  dislocation,  in  the,  living  bodv,  and 
but  once  upon  the  dead  subject. 


322  DISLOCATIONS   OF    ELBOW. 

Dislocation  of  the  Radius  outwards. — Thh  acci- 
dent occurs  more  frequently  than  the  last,  accord- 
ing to  the  testimony  of  every  Surgeon  of  practical 
experience.  The  head  of  the  bone  is  then  on  the 
outer  side  of  the  external  condyle,  where  it  may  be 
felt  under  the  skin,  rolling  as  the  hand  is  moved.  W 
The  natural  motions  of  the  joint  are  materially  in- 
terfered with,  and  pain  follows  every  movement. 

Treatment. — Reduction  is  accomplished  by  mak- 
ing traction  at  the  wrist,  and  bending  the  limb  at 
the  elbow. 

Retention  is  effected  as  in  the  other  cases  of  dis- 
location already  described. 

In  compound  dislocations  of  the  elbow  joint,  the 
arm  must  be  flexed  and  placed  in  the  most  comfort- 
able and  convenient  position,  the  angular  splints 
applied,  when  practicable,  and  the  antiphlogistic 
treatment  resorted  to.  After  a  few  weeks  have 
expired,  and  the  external  wound  is  in  good  condi- 
tion an  effort  may  be  made  to  reduce  the  disloca- 
tion. 

Dislocations  of  the  Wrist  Joint. — Fractures  of  the 
lower  end  of  the  radius  are  frequently  mistaken  for 
dislocations  of  the  wrist  joint,  sofrequently  in  fact 
that  some  Surgeons  have  denied  the  existence  o 
such  dislocations  under  all  circumstances.  The 
.  carpus  as  a  whole  may  be  dislocated  either  back 
wards  or  forwards.  The  existence  of  a  smooth  con 
vex  swelling  corresponding  with  $ie  first  row 
carpal  bones  either  upon  the  upper  or  under  surface 
of  the  wrist  together  with  some  shortening  of  the 
forearm,  and  an  unusual  prominence  of  the  styloic 


DISLOCATIONS   OF   WRIST.  323 

processes  of  the  radius  and  ulna,  are  the  guides  bv 
which  these  dislocations  may  bo  recognized. 

Reduction  is  readily  accomplished   by  the  em- 
ployment of  i  isieh, — a  cir- 
■  curostance  which  will  facilitate  the  diagnosis  be- 
.  tween  this  accident  and  impacted  fracture  ot  the 
radius. 

.Retention  is  effected  by  means  of  anterior  and 
'  posterior  splints. 

The  radius  alone  is  sometimes  thrown  forwards 
1  upon  the  carpus.  • 

Symptoms.— The  outer  side  of  the  hand  is  displaced 
••  backwards  and  the  inner  forwards,  while  the  extre- 
mity of  the  bone  forms  a  protuberance  upon  the  fore- 
part   of   the   wrist.      Reduction   and    retention    nre 
effected  as  when  both  bones  are  displaced. 

The  ulna  is  sometimes  separated  from  the  radius 
by  the  rupture   of  the   sacriform    ligament,    and 
,  usually  projects  backwards. 

Symptoms. — This  accident  may  be  known  by  an 
elevation  immediately  above  the  level  of  the  os- 
pmeiform,  which  is  easily  reduced  by  pressure  to 
ita  former  situation. 

Treatment. — Press  the  bone  bank  to  its  proper 
place,  with  the  linger. 

Apply  a  compress  of  leather  to  the  extremity  of 
the   ulna;  place  splints  along  the  forearm:   and 
I  use  a  roller  to  keep  them  in  position. 

Dislocation  of  the  bones  of  the  Carpus. — This  ac- 
I  cident  is  of  rare  occurrence,  and  is  usually   the  re- 
sult of  falls  upon  the  hand. 

The  os-r^gnum  is  the  bone  most  frequently  dis- 
placed. 


234  DISLOCATIONS  OF  THUMB. 

Symptoms. — A  round  hard  tumour  on  the  back 
of  the  wrist,  opposite  the  metacarpal  bone  of  the 
little  finger,  presenting  itself  .immediately  suhse-, 
quent  to  a  fall  upon  the  hand. 

Reduction. — Extend  the  hand  and  apply  pressure 
upon  the  tumour. 

Retention. — Apply  compresses,  ami  enjoin  abso- 
lute rest. 

Instances  are  on  record  of  the  dislocation  of  the 
pisiform  and  semilunar  bones,  but  these  are  very  un- 
usual accidents. 

Sometimes  ganglia  arc  mistaken  for  dislocations 
of  these  bones,  but  these  are  easily,  removed  by 
striking  them  sharply  with  the  fiat  surface  of  a 
book,  Avhen  the  supposed  dislocation  immediately 
disappears. 

A  compound  dislocation  of  the  carpal  bones  fre- 
quently happens,  and  is  generally  produced  by  the 
bursting  of  guns,  by  the  hand  being  caught  in  ma- 
chinery, or  by  the  passiug  of  heavy  bodies  over  it. 
In  such  cases  one  or  two  of  the  carpal  bones  may  be 
dissected  away,  without  destroying  the  hand  or  Re'-* 
riously  interfering  with  its  motions. 

If  great  injury  be  done,  amputation  becomes  ab- 
solutely necessary. 

Dislocation  of  the  Metacarpal  bone  of  the  Thumb. — 
This  is  the  only  metacarpal  bone  ihat  admits  of  dis 
location,  and  this  accident  seldom  occurs.  These 
luxations  have  been  observed  in  two  directions  :  • 
backwards  and  forwards,  and  can  readily  be  recog- 
nized and  reduced — extension  being  mad flfrom  the 
thumb  by  means  of  a  piece  of  tar>»  applied  around 
the  first  phalanx. 


DISLOCATIONS   OF  THUMB.  325 

Dislocation  of  the  First  Phalanx  of  the  7hwrib.  — 
Theboue  is  usually  dislocated  backwards  but  may 
be  thrown  forwards  also. 

Symptoms. — The  proximal  extremity  of  the  ] 
anx  slides  back  upon  the  distal  extremity  of  the 
metacarpal  bone,  in  the  backward  dislocation,  and 
stands  off  from  it  at  nearly  a  right  angle,  while 
the  metacarpal  bone  projects  strongly  in  the  pi  lm 
of  the  hand.  In  very  rare  cases  the  phalange:  tre 
extended  upon  the  metacarpal  bone  in  a  straight 
line. 

In  the  forward  dislocation,  the  first  phalanx  is 
in  front  or  the  metacarpal  bone,  and  in  the  same 
plane;  while  the  •  last  phalanx  is  inclined  slightly 
back. 

•  Ireatment. — If  the  dislocation  be  backward, 
ben  the  dislocated  phalanx  forcibly  backwards 
until  it  stands  upon  its  articulation,  hold  it  in  th  t 
position,  and  at  the  same  time  press  against  tbe 
distal  extremity  of  the  metacarpal  bone.  Mai  e 
firm  pressure  againsl  the  base  of  the  disloe 
phalanx,  and  slid"  it  into  its  place. 

If  this  fail,  bend  the  thumb  towards  he 
palm  of  the  hand,  in  order  to  relax  the  flexor  i 
cles  as  much  as. possible,  and  then  make  extension 
by  means  of  the  clove-hitch.  The  apparatus  of  Le- 
vis may  be  also  used  in  this  connexion.  If  the  dido- 
cation  cannot  be  reduced  by  these  means,  div,.  e 
one  of  the  short  floxoBS  of  the  thumb,  and  the  re- 
duction can  be  readily  effected.  The  author  ig 
convinced  that  this  is  more  properly  speaking,  in 
many  instances,  a  dislocation  w'the  distal  end  of 
the  metacarpal  bone,  and  that  reduction,  can  bi- 
ll 


2b  DISLOCATIONS  OF  THIGH. 

most  readily  ensured  by  fixing  the  thumb  firmly, 
and  manipulating  from  the  direction  of  the  arm. 

"When  the  dislocation  is  forward,  reduction  may 
be  effected  by  seizing  the  thumb  in  the  palm  of 
the  hand,  and,  with  the  fingers  resting  upon  the 
back  of  the  patient's  hand,  forcing  the  phalanges 
into  flexion  by  firm  and  steady  pressure. 

Dislocations  of  the  phalanges  of  the  fingers  may  be 
reduced  on  the  same  principles. 

Dislocations  of  the  Lower  Extremities. — Dis- 
locations'of  the  Thigh. — There  are  four  principal  dis- 
locations of  the  femur  which  should  be  thorough- 
ly studied  and  understood  by  the  Surgeon,  viz  : 
upwards  and  backwards  upon  the  dorsum  ilii ;  up- 
wards and  backwards  into  the  ischiatic  notch ; 
downwards  and  forwards  into  the  thyroid  foramen; 
and  upwards  and  forwards  on  the  pubes. 

1.  Dislocation  upwards  and  backwards  on  the 
dorsum  ilii. 

Causes. — Falls  from  a  height  when  the  force  of 
the  concussion  is  received  upon  the  outside  of  the, 
knee  ;  falls  upon  the  foot  or  knee  when  the  limb  is 
abducted  ;  a  heavy  weight  striking  the  pelvis  from 
above,  the  body  being  bent  forward  ;  or  any  thing 
which  forces  the  thigh  into  extreme  abduction  or 
abduction  united  with  rotation  inwards. 

Symptoms. — The  limb  is  shortened  ;  the  thigh  is 
rotated  inwards  and  somewhat  flexed  ;  the  great 
toe  rests  upon  the  instep  of  the  foot  of  the  sound 
limb ;  the  knee  touches  the  opposite  thigh  near 
the  upper  margin  of  the  patella ;  the  body  of  the 
patient  is  slightly  bent  forwardi ;  the  roundnesa  of 


DISLOCATIONS  OP  THIGH.  327 

the  hip  is  lost ;  the  trochanter  major  is  depressed  ; 
aud  the  head  of  the  bone  can  be  felt  in  its  new  po- 
sition. 

Treatment. — The  dislocation  may  be  reduced  by 
manipulation  or  by  mechanical  force,  (extension 
and  counter  extension). 

Manipulation. — Hippocrates  first  described  this 
method  of  reduction,  though  it  has  been  variously 
modified,  illustrated  and  improved  by  Wiseman, 
Turner,  Anderson,  Physic,  Smith,  Oolombat.  Reid 
and  others. 

Directions. — Place  the  patient  in  the  horizontal 
posture  on  a  narrow  table  covered  with  blankets. 
and  on  his  sound  side.  Secure  the  body  firmly  by 
folding  a  sheet  several  times  lengthwise,  then  ap- 
ply the  middle  of  the  band  thus  made,  to  the 
inner  and  upper  part  of  the  sound  thigh,  carry  its 
extremities  under  "the  table,  pass  them  obliquely 
up,  cross  them  again  firmly  over  the  trunk  above 
the  injured  hip,  and  secure  the  ends  under  the  ta- 
ble. 

Administer  chloroform  freely  ;  stand  at  the  pa- 
tient's back;  grasp  the  knee  of  the  dislocated 
limb  with  the  right  hand  and  the  ankle  with  the 
left — if  the  left  femur  be  dislocated  reverse  the 
hands ;  flex  the  leg  upon  the  thigh ;  rotate  the 
thigh  outwards  ;  then  slightly  abduct  the  thigh  by 
pressing  the  knee  outwards  ;  and  lastly  thrust  the 
knee  upwards  towards  the  face,  so  as  to  flex  the 
thigh  freely,  and  at  the  3ame  moment  increase  the 
abduction  of  the  limb.  This  is  the  plan  of  Nathan 
Smith,  as  described  by  his  son,  the  distinguished 
Professor  of  Surgery  in  the  University  ff  Mary- 
land. 


328  DISLOCATIONS  OF  THIGH. 

Mechanical    Means. — Reduction   by    extension 
dates  back  to  Hippocrates,  but  Ambrose  Pare  was 
the  first  to  recommend   the  use  of  pullies.     The 
plan  to  be  pursued  in  this  connexion  is  as  follows: 
place  the  patient  upon  a  bed  of  suitable   height, 
on  his  back  and  slightly  turned  on  the  sound  side; 
drive  a  staple  into  the  wall  oi  the  room   upon  one 
side  and  another  into  the  wall  upon   the   opposite 
side,  both  corresponding  with  the  line  of  the  shaft 
of  the  femur,  but  the  one   in   front   being   higher 
.  and  the  one  behind  being  lower  than  the  bed  ;  lay 
two  pieces  of  strong  cloth,   four  inches    wide  and 
four  feet  long,  on  either  side  of  the  limb,  the  centre 
of  each  being  just  above  the  two  condyles ;  over  the 
centre  of  these   two  strips   apply  a  strong   roller 
tightly,  previously  wetted  in    water ;  bring  down 
the  upper  ends  of  the  side  strips  and  fasten   them 
to  the  lower,  so  as  to  form  two  loops,  upon   which 
one  of  the  hooks  of  the  compound  pulley  is  to  be 
made  fast,  while  the  other  hook  is  secured  to   the 
front  staple  in  the  wall ;  fold   a  sheet  diagonally, 
and  adjust  it  so  that  its  centre  applies  to  the  peri- 
toneum while  its  ends  are  tied  to  the  lower  staple ; 
pass  underneath  the  upper  part  of  the  dislocated 
limb,  a  strong,  broad  bandage  of  sufficient  length 
to  tie  over  the  neck  of  the  Surgeon  when  stand- 
ing about  half  bent;  place  assistants  on  either  side 
of  the  patient  to  keep  him  in  position ;  everything 
thus  prepared,  administer  chloroform,  make  exten- 
sion by  means  of  the   pulley,  and  counter   exten- 
sion by  means  of  the  sheet,  in  the  line  of  the   axis 
of  the  dislocated  limb ;  place  the  hand  carefully 
upon  the  trochanter  major,  and  watch  carefully  its 


DISLOCATIONS   OF  THIGH.  329 

descent;  and  then  when  the  head  of  the  bone  has 
nearly  or  quite  reached  its  socket,  if  it  does  imme- 
diately get  into  position,  lift  up  the  thigh  by 
means  of  the  hand,  which  has  been  passed  under 
it,  and  the  luxation  will  generally  be  reduced. 

If,  after  all,  the  bone  does  not  enter  the  socket, 
the  flexion  of  the  limb  may  be  increased  or  dimin- 
ished, the  tension  suddenly  released,  and  "mani- 
pulation "  attempted- 

The  extending  force  may  be  applied  also  by 
means  of  a  leather  belt,  strips  of  adhesive  plaster, 
&c  :  while  a  small  rope  doubled  upon  itself,  with  a 
stick  passed  through  it,  may  be  substituted  for  the 
pulley.  Bloxham,  u  dislocating  tourniquet,"  and 
Jarvis'  adjuster  may  also  be  employed  in  this  con- 
nexion. 

2.  Dislocation  upwards  and  backwards  into  the 
great  ischiatic  notch. 

Causes. — Falls  upon  the  foot  or  knee,  when  the 
limb  is  very  much  in  advance  of  the  body;  heavy 
blows  upon  the  back  and  pelvis  when  the  thigh  is 
nearly  at  right  angle  with  the  body,  &c. 

Symptoms. — The  limb  is  shortened,  but  not  so 
much  as  in  the  last  named  dislocation  ;  the  thigh 
is  flexed,  adducted  and  rotated  inwards  ;  the  toe 
of  the  dislocated  limb  touches  the  ball  of  the  great 
toe  on  the  other  side ;  the  knee  is  not  carried  so  far 
over  the  other  as  in  the  former  luxation  ;  the  tro- 
chanter major  is  approximated  towards  the  anteri- 
or superior  spinous  process  of  the  ilium;  and  the 
lumbar  part  of  the  spine  is  so  arched  that  it  can- 
not be  straightened  so  long  as  the  thigh  is  straight 
or  on  a  line  with  the  patient's  trunk. 


DISL0CATIN8  OF   THIGH. 

Treatment. — Manipulation  maybe  employed,  pre- 
cisely as  described  above,  though,  the  extentofthe 
circuit  to  be  described  by  the  head  of  the  bone  is 
inconsiderable,  while  there  is  great  danger  of  its 
being  thrown  into  the  foramen  thyroideum. 

Extension. — Arrange  every  thing  as  before  des- 
cribed, taking  care  to  have  the  "front  staple  "  at 
a  greater  height  from  the  floor  ;  administer  chlo- 
roform ;  make  extension  at  an  angle  of  45°  ;  and 
when  sufficient  force  has  been  applied  lift  the 
thigh  upwards  by  means  of  the  band  passed  under 
the  thigh  and  carried  over  the  operator's  shoulder. 
Bransly  Cooper  says  that  the  limb  should  be  flexed 
quite  to  a  right  angle  while  extension  is  being 
made. 

Be  careful  that  the  "  counter  extending  "  band 
does  not  slide  off  the  pelvis  toward  the  upper  part 
of  the  thigh. 

3.  Dislocations  downwards  and  forwards  into 
the  foramen  thyroideum. 

Causes. — Falls  upon  the  foot  or  knee  while  the 
limb  is  abducted,  and  the  falling-  of  a  heavy  weight 
upon  the  back  the  body  being  bent  and  the  thighs 
spread  asunder. 

Symptoms. — The  thigh  is  lengthened  one  or  two 
inches,  abducted,  flexed,  and  advanced ;  the  body  is 
bent  forwards  or  slightly  flexed  upon  the  thigh  ; 
the  toes  point  directly  forwards  as  a  general  thing ; 
the  hip  is  flattened ;  the  trochanter  is  less  promin- 
ent;  and  the  head  -..-f  the  bone  may  be  often  felt 
in  its  new  position. 

Treatment.-- Manipulation,  This  dislocation  may 
be  readily  reduced  by  manipulation  if   conducted 


DISLOCATIONS  OF  THKJH.  881 

in  the  following  manner ;  abduct  the  limb  ;  carry 
it  up  towards  the  body  until  the  progress  :  £  the 
knee  is  arrested;  then  carry  the  limb  inward  ;  and 
finally  bring  it  down  adducted.  'When  th  :nee 
is  opposite  the  pubes,  rotate  the  femur  quk^  /  in- 
wards, and  give  it  a  slight  rocking  motior.  Ex- 
tension: Sir  A.  Cooper  advises  that  exten  1  be 
made  in  the  following  manner;  place  the  ient 
on  his  back  with  thighs  separated ;  make  the  '  leys 
fast  to  a  band  drawn  through  the  perineum  oi  the 
affected  side,  in  a  direction  upwards  and  out  vr.rds; 
pass  a  counter  band  around  the  pelvis  through  the 
band  attached  to  the  pulleys,  and  attach  it  to  a 
staple  driven  in  the  wall;  administer  Chloroform; 
make  traction  with  the  pulleys  until  the  head  of 
the  bone  is  felt  moving  from  its  position ;  then 
seize  the  ankle  and  adduct  the  limb  forcibly. 
Place  the  patient  in  bed  and  rotate  the  lirab  in 
wards,  keeping  the  knees  together. 

4.  Dislocation  upwards  and  forwards  upon  the 
pubes. 

Causes. — Falls  upon  the-  foot,  when  the  leg  is 
thrown  backwards  ;  putting  one  foot  into  a  hole 
while  walking  and  falling  backwards;  and  falls  or 
blows  upon  the  back  of  the  pelvis. 

Symptoms — The  thigh  is  shortened,  flexed  slight- 
ly and  rotated  outwards  ;  tiie  trochanter  cannot  be 
distinguished;  the  head  of  the  bone  can  be  felt  on 
the  pubes  or  outside  of  the  femoral  artery. 

Treatment. — Manipulation.  Numerous  instances 
of  the  reduction  of  this  dislocation  by  manipula- 
tion, are  on  record,  though  the  methods  pursued 
were  different.     The  best  plan,  is  as  follows,  ab- 


*    1  DISLOCATIONS   OF   THIGH. 

ict  the  limb  and  forcibly  rotate  it  outwards  ;  flex 

upon  the   body;  then  adduct  it,  and  bring   it 

vra  upon  the  table.     Care  should  be  taken  not 

>  continue  the  rotation  outwards  after  the  head 

'"the  femur  Las  risen  above  the  pubes,  but  on  the 

Qtrarv  to  rotate  it  gently  inwards  so  as  to  enable 

ae  head  to  slide  under  the  psoas  and  iliacus  in- 

mus   muscles   towards   its    socket.     Extension. 

i  ay  the  patient  on  his  back  upon  the  table ;  make 

fh  3  extending  band  fast  above  the  knee  and  attach 

'o  a  staple  driven  in  the  floor;  pass  the  counter 

'ending  band  ur^er  the  perineum  and  attach  it 

.   staple  above  the  level  of  the  table  ;  administer 

,  of'orm ;  make  steady  and  persistent  extension ; 

i   \  when  the  head  of  the  femur  has  begun  to  move, 

iie  upper  part  of  the  thigh,  as  before  described, 

>>  to  carry  the  head  of  the  bone  into  its  socket. 

.ere  are  three  cardinal  principles  which  should 

;      membered  in  this  connexion,  viz  : 

in  reducing  by  manipulation,  carry  the  limb 
in  those  directions  in  which  it  is  found  to 
easily. 

In  reducing  by  extension  apply  the  force  in 
ction  of  the  axis  of  the  dislocated  limb." 
eduction  has  been  effected,  particular- 
much  force  has  been  used,  keep   the   patient 
<•  ly  in  bed,  with  his   knees   brought  together 
u   t:    all  danger  of  inflammation  and  recurrence  of 
accident,  have  passed. 
VTi  rious  other  anomalous  dislocations  may  occur 
ib is  connexion,  for  an    account   of  which  the 
•is  referred  to   the  standard  works   on   the 
oU  >kct, 


DISLOCATIONS   OF   PATELLA.  358 

Dislocations  of  the  Patella. — This  bone  may  b« 
dislocated  either  outwards,  inwards,  upwards  or 
upon  its  own  axis. 

Causes. — Muscular  action  of  a  sudden  and  spas- 
modic character;  blows  ;  falls,  &c. 

Symptoms. — The  altered  position  of  the  bone  ; 
the  prominence  of  either  condyle  ;  the  immovable 
condition  of  the  limb;  great  pain;  and  slightly 
bent  condition  of  the  knee. 

Treatment. — The  treatment  consists  in  relaxing 
the  quadriceps  extensor  muscle,  in  extending  the 
leg,  in  carrying  the  body  forward,  and  then  press- 
ing the  bone  into  position. 

Dislocation  of  Hie  Lead  of  the  Tibia. — The  head  of 
the  Tibia  may  be  dislocated  backwards,  forwards, 
inwards,  outwards,  and  backwards  and  outwards 
though  the  accident  is  of  rare  occurrence. 

Dislocation  of  the  head  of  the  Tibia  backwards. 
Canses.  Violent  blows  upon  the  lower  end  of  the 
femur  or  upper  end  of  the  tibia  ;  and  by  the  twist- 
ing of  the  tibia  when  the  foot  is  made  fast  in  a  hole 
and  the  body  swings  around  upon  the  knee. 

Symptoms. — The  head  of  tibia  may  be  felt  in  pop- 
liteal space  pain  in  consequence  of  pressure  upon 
the  popliteal  nerve;  a  depression  immediately  be- 
low the  patilla  ;  the  condyles  of  the  femur  project- 
and  the  limb  usually  somewhat  flexed. 

Treakjirat. — Manipulation  may  succeed  if  the 
injury  be  very  recent  or  the  shock  great.  The 
limb  should  be  carried  in  those  positions  in  which 
it  moves  most  easily  ;  but  if  this  fails  then  forced 
flexion  should  be  resorted  to,  rocking  the  limb 
from   one   side   to   another,  »«d    making  strong 


334  DISLOCATIONS    OF    TIBIA. 

pressure  upon  the  projecting  bones  of  the  joint. 
Extension  may  be  practised  by  making  a  strong 
assistant  seize  the  limb  above  the  ankle,  and  pull 
forcibly  in  the  direction  of  the  axis  of  the  limb. 
The  pulleys  may  also  be  employed.  Counter  ex- 
tension may  be  made  from  the  perineum,  or  from 
the  lower  and  under  part  of  the  thigh.  Disloca- 
tion forwards.  The  causes  by  which  this  accident 
is  produced,  are  similar  to  those  mentioned  above. 

Symptoms. — The  patella,  fibula  and  tibia  are 
prominent  in  front,  while  the  condyles  of  the 
femur  may  be  felt  behind;  the  limb  is  shortened; 
and  the  circulation  is  interrupted  by  pressure  upon 
the  artery. 

Treatment. — Manipulation  may  possibly  succeed 
if  attempted  immediately.  Extension  and  counter 
extension  should  be  made  as  described  above. 

Dislocation  outwards.—  Causes.  A  violeut  wrench 
of  the  knee  joint,  may  rupture  the  ligaments,  and 
cause  this  accident. 

Symptoms. — The  inner  condyle  of  the  femur 
projects,  while  the  head  of  the  tibia  and  fibula  can 
be  distinctly  felt  on  the  outer  side  of  the  joint. 

Treatment. — The  treatment  does  not  differ  from 
that  of  the  other  dislocations  just  described. 

In  the  dislocations  inward  and  outward  and 
backward  there  is  nothing  peculiar,  and  the  acci- 
dent,   should  be  treated  on  general  principles. 

Dislocations  of  the  Lower  end  of  the  Tibia. — The 
tibia  may  be  dislocated  at  its  lower  end  in  four 
directions,  namely  :  Inwards,  outwards,  forwards 
and  backwards.     Most  of  these  accidents   compli- 


DISLOCATIONS   OF  TIBIA.  335 

cate  themselves  with  fractures,  of  the  two  bones  of 
the  leg,  one  or  both. 

Dislocation  inward,  Causes.  Falls  from  a  height 
upon  the  bottom  of  the  foot,  which  at  the  same 
time  is  turned  outwards  ;  blows,  and  violents  twists 
of  the  foot  outwards. 

Symptoms. — Foot  is  abducted ;  the  internal  mal- 
leolus projects  strongly;  there  is  a  corresponding 
depression  upon  the  outer  side  of  the  ankle ;  the 
pain  is  great ;  motion  is  lost,  though  the  surgeon 
can  move  the  foot ;  and,  fracture  of  fibula  when 
the  dislocation  is  complete. 

treatment. — Seize  upon  the  foot,  and  forcibly 
adducting  it,  taking  pains  to  Ilex  the  leg  so  as  to 
relax  the  gastrocnemius  muscle,  and  to  give  the 
part  a  gentle  rocking  motion.  If  this  fails,  bend 
the  leg  up  a  right  angle  to  the  thigh  ;  pass  a  coun- 
ter extending  band  around  the  thigh ;  attach  the 
pulleys  to  the  foot  by  means  of  a  bandage  carried 
around  it ;  and  then  make  forcible  extension. 

Dislocation  outwards. — Causes. — The  causes  are 
similar  to  those  which  produce  the  last  named  ac- 
cident, only  the  position  of  the  foot  is  reversed. 

Symptoms. — The  foot  is  adducted ;  the  external 
malleolus  projects  ;  there  is  a  depression  upon  the 
inner  side  of  the  foot,  &c. 

Treatment. — The  outward  dislocation  may  be  re- 
duced precisely  in  the  same  manner  as  the  disloca- 
tion inwards. 

Dislocation  forwards. — Causes. — Violent  exten- 
sion of  the  foot  upon  the  leg ;  falls  upon  an  in- 
clined plane  ;  blows  upon  the  tibia,  &c. 

Symptoms.— The  length  of  foot  in  front  of  tibia  is 


236  DISLOCATIONS   OF   TIBIA. 

diminished,  while  the  projection  of  the  heel  is  in- 
creased ;  the  toes  are  turned  downwards;  the  heel 
:s  drawn  upwards ;  the  end  of  the  tibia  can  be 
felt;  and  the tendo-Achillis  is  curved  forwards  and 
tense. 

Treatment. — Flex  the  leg  upon  the   thigh,  make 

extension  from  the  foot;  and  at   the    same   time^ 

press  in  front  of  the  tibia  and   against  the   heel. 

11  the  bone  begins  to  slide  into  its   place,  the 

fov)    should  be  forcibly  flexed  upon  the  leg. 

T  islocation  backwards.  This  is  so  rare  an  acci- 
dent that  Malgjugne  has  only  succeeded  in  collec- 
ting five  examples.  It  is  produced  by  causes  ex- 
actly the  reverse  of  those  which  operate  in  the  pro- 
duction of  the  last,  while  the  signs  which  distin- 
guish itare  directly  opposite  to  those  last  described. 
Reduction  should  be  attempted  by  a  method  simi- 
lar to  that  recommended  for  other  dislocations  of 
the  ankle  joint. 

The  Fibula  may  also  be  dislocated  both  at  its 
upper  and  lower  end,  but  these  accidents  are  of 
such  rare  occurrence,  and  so  readily  distinguished 
as  to  preclude  the  necessity  for  a  more  detailed 
account  of  them. 

Dislocation  of  t fie  Astragalus. — Ca  uses. — The  same 
as  those  which  produce  dislocation  of  the  Tibia. 

Symptoms. —  Prominences  according  as  the  bone 
is  displaced  inwards,  outwards,  backwards  or  for- 
wards; lateral  deviation  of  the  foot;  shortening  of 
the  leg,  &c. 

Jreament.-^ Reduce  if  possibly  by  means  of  ex- 
tension pressure,  &c,  but  if  unsuccessful,  resect  or 
amputate.     Keep  down  tlje   inflammation,  which 

always  intense. 


DISLOCATIONS    OF    CALCANEUS.  387 

The  Astragalus  may  also  be  separated  from  the 
Scaphoid  bone,  and  should  be  treated  on  the  same 
principles. 

Dislocation  of  the  Calcanevm. — Causes. — Falls 
upon  the  heel  and  direct  blows. 

Symptoms. — Prominences  and  depressions  ac- 
cording as  the  dislocation  is  outward,  upwards  and 
inwards. 

Treatment. — Bend  the  thigh  and  knee  on  the 
body;  Hex  the  leg  ;  seize  the  metatarsus  and  the 
heel;  draw  the  foot  directly  from  the  leg;  and 
press  the  knee  against  the  outside  of  the  joint. 

The  Scaphoid,  the  Cuneiform  bones,  the  ps-cu- 
boides  and  metatarsal  bones  are  all  subject  to  dis- 
locations, which  can  be  recognized  without  much 
difficulty  and  which  should  be  treated  on  the  same 
general  principles  as  the  bones  of  the  foot  already 
referred  to  above. 


CHAPTER  VIII 


FRACTURES. 

Fractures  in  General. — The  term  fracture  is 
derived  from  a  Greek  word  which  signifies  "to 
break,"  and  is  employed  to  convey  the  idea  of  a 
division,  by  violence,  of  bone  or  cartilage. 

Classification. — The  following  is  the  most  simple 
and  convenient  classification  of  fractures: 

All  fractures  are  : 


INCOMPLETE 

Embracing. 

Fissures, 

Depression, 

Curvature, 

Flexion, 

Splintering, 

Perforations. 


OR  COMPLETE. 

Embracing. 
Transverse  fractures, 
Serrated        " 
Oblique 
Impacted       " 
Stellated. 


EITHER  OF  WHICH  MAY  BE  : 

Simple, 
Compound, 
Comminuted, 
Complicated. 

Incomplete  Fractures. — These  involve  the  divis- 
ion of  only  a  portion  of  the  thickness  of  the  bone, 
and  embrace. 


INCOMPLETE    FRACTURE*.  339 

1.  Fissures. — The  experience  of  all  Surgeons 
confirms  the  fact  that  both  flat  and  long  bones  may 
be  cracked,  in  any  direction  as  the  result  of  violence, 
without  a  solution'  of  their  entire  continuity.  The 
symptoms  which  mark  this  accident  are  those  of 
contusion  of  the  bone,  and  depend  upon  the  devel- 
opment of  periostitis,  or  of  suppuration  in  the  me- 
dullary canal  or  internal  structure  of  the  bone. 

2.  Depression. — This  term  is  employed  to  de- 
signate the  circumscribed  fracture  of  a  part  of  the 
thickness  of  a  flat  bone  with  more  or  less  flexion  of 
the  portion  which  remains  intact.  Depression 
has  been  observed  in  the  bones  of  the  cranium, 
ribs,  scapula,  neck  of  the  femur,  and  of  the  dia- 
physes  generally.  This  accident  can  readily  be 
determined,  in  a  majority  of  cases,  by  thrusting  the 
finger  into  the  depressions. 

3.  Flexion. — The  long  bones  may  all  be  bent  in 
the  direction  of  their  diameter,  as  the  result  of  a 
similar  lesion.  Under  these  circumstances  there  is 
not  simple  curvature,  but  positive  fracture  of  a 
portion  of  the  thickness  of  the  bone,  save  in  the 
case  of  very  young  subjects. 

This  accident  occurs  most  commonly  in  the 
bones  of  the  fore  arm ;  then  in  the  thigh ;  and 
lastly  in  the  leg.  The  young — those  between  the 
ages  of  five  and  thirteen — are  more  subject  to  it 
than  persons  of  mature  years. 

The  bone  is  generally  more  or  less  curved,  with 
a  salient  angle  on  the  side  of  the  fracture  ;  while 
the  curvature  can  be  diminished  but  rarely  over- 
come by  pressure. 

4.  Splintering.— There  may  be  a  complete  sepo- 


340  INCOMPLETE   FRACTURES. 

ration  of  a  mere  splinter  while  the  houe  itself  re- 
mains nearly  solid.  Fractures  of  this  description 
are  usually  produced  by  blows  of  a  sabre,  or  by 
falls  grazing  the  bone,  and  may  occur  in  any  part 
of  the  body,  though  the  skull  is  most  frequently 
the  locality  of  the  accident*  The  splinter  can  usu- 
ally be  felt  and  the  diagnosis  is  not  difficult. 

5.  Perforations. — The  bone  may  be  perforated 
through  and  through  or  in  one  portion  of  its  thick- 
ness by  foreign  bodies,  particularly  by  balls,  with- 
out the  complication  of  splinters  or  comminution. 
In  the  one  instance  the  perforation  is  said  to  be 
complete  and  in  the  other,  incomplete.  These  lesions 
have  been  observed  in  all  the  bones  of  the  body, 
and  are  of  constant  occurrence,  though  true  perfo- 
rations occur  most  frequently  in  the  bones  of  the 
skull,  and  the  head  of  tht'  femur  and  tibia.  These 
accidents  are  generally  serious.  The  surrounding 
soft  parts  swell  and  inflame  ;  the  bone  also  takes 
on  inflammatory  action  ;  the  limb  becomes  cede- 
matous  ;  a  foetid  reddish  pus  flows  from  the  wound ; 
while  a  probe  introduced  into  it  shows  that 
the  bone  is  soft  and  easily  broken  down.  The 
splinters  are  detached  and  float' out  with  the  puru- 
lent matter  ;  and  either  the  work  of  repair  is  com- 
menced, or  caries  is  developed,  fistula?  are  produced, 
a  tedious  suppuration  ensues,  and  amputation  or 
resection  becomes  the  only  available  remedy.  The 
great  indication  is  to  extract  the  foreign  body,  in 
the  premises,  if  the  perforation  be  an  incomplete 
one.  The  wound  should  then  be  detached  on  gen- 
eral principles. 
Complete  Fractures.     When  the  bone  is  divided 


COMPLETE   FRACTURES.  341 

to  the  extent  of  its  whole  thickness,  the  fracture 
is  said  to  be  complete.  Fractures  of  this  kind 
are: 

1.  Transverse.  When  the  line  of  fracture  forms 
a  right  angle  with  the  long  diameter  of  the  bone, 
or  deviates  from  the  perpendicular  so  slightly  a?  per- 
mits the  ends  of  the  bone  to  rest  upon  each  other, 
or  when  replaced  not  to  become  spontaneously  dis- 
placed, the  fracture  is  transverse. 

2.  Serrated  Fractures. — When  the  opposite  sur- 
faces denticulate,  the  elevations  upon  one  fragment 
being  reflected  by  corresponding  depressions  in  the 
other,  the  fracture  is  serrated.  A  majority  of  frac- 
ture from  simple  blows  are  of  this  character;  but 
they  occur  principally  in  the  clavicle,  humerus, 
radius,  ulna,  femur,  and  tibia. 

3.  Oblique  Fractures. — When  the  line  of  frac- 
ture forms  an  angle  with  the  shaft  of  the  bone  not 
far  from  45°,  the  fracture  is  oblique.  When  the 
obliquity  is  less  than  forty-five  degrees,  the  frac- 
ture becomes  transverse,  when  greater,  it  is  styled 
a  fracture  en  bee  dc  flute,  and  when  it  approaches 
parallism  to  the  axis  of  the  bone,  it  is  called  a  lon- 
gitudinal fracture.  These  fractures  are  generally 
produced  by  indirect  violence,  and  usually  have 
something  peculiar  in  their  aspect,  according  to  the 
cause  producing  them. 

4.  Impacted  fractures. — When  the  ends  of  the 
bone  are  driven  into  each  other,  the  lamellated 
structy«|  of  one  fragment  penetrating  the  cancel- 
lous structure  of  the  other,  the  fracture  is  said  to  be 
impacted. 

6.  Stellated  Fractures. — When  some  cutting  in- 


£42  COMPLETE   FRAOTUaES. 

gtrument  or  a  ball  is  driven  through  the  bone,  par- 
ticularly if  it  be  a  flat  one,  innumerable  spiculee 
will  in  many  instances  be  found  projecting  from 
the  margins  of  the  perforation.  The  projection  or 
radiation  of  these  fragments  from  a  central  point 
gives  the  fracture  a  stellated  or  star  like  appear- 
ance; and  hence,  the  name  of  the  fracture.  This 
\accident  occurs  frequently  in  connexion  with 
the  bones  of  the  cranium,  most  seriously  compli- 
cating those  accidents. 

In  addition  to  these  distinctive  characteristics, 
there  are  some  features  which  may  connect  them- 
selves with  either  incomplete  or  complete  frac- 
tures. Thus  both  varieties  of  fracture  may  be 
either  simple,  compound,  comminuted  or  compli- 
cated. 

1.  Simple  Fracture. — By  this  term  is  usually 
meant  the  fracture  of  a  bone  simply  at  one  point, 
without  reference  to  the  question  of  complications. 
A  more  correct  and  convenient  arrangement  would 
extend  its  meaning  thus  :  "a  fracture  simply  at 
one  point  without  injury  to  the  soft  parts." 

2.  Compound  Fracture. — "When  there  is  an  ex- 
ternal wound  communicating  with  a  fracture  of 
the  bone,  whether  complete  or  incomplete,  the  in- 
jury is  recognized  as  a  compound  Fracture. 

3.  Comminuted  Fracture. — When  the  bone  is 
broken  at  more  than  one  point,  and  there  are  more 
than  two  fragments,  the  fracture  is  "  multiple  "  or 
comminuted. 

4.  Complicated  Fracture. — A  fracture  is  said  to 
be  complicated,  when  in  addition  to  the  division 
of  the  bone,  there  is  injury  either  of  some  impor-i 


AAT7SB*    OV   FRACTURM.  S4S 

tant  vessel  or  nerve,  great  contusion  or  laceration 
of  the  soft  parts,  fracture  of  neighbouring  bones, 
dislocation,  or  constitutional  injury. 

(  'uses  of  Fractures. — The  causes  of  fractures  are 
predisposing  and  exciting. 

!  disposing  Causes. — In  childhood  the  bones 
arc  soft  and  easily  bent,  and  in  old  age  they  are 
harder  and  more  brittle.  'Females  are  less  liable 
to  fracture  than  males  except  in  old  age.  Moro 
fractures  occur  in  winter  than  in  summer.  Mol- 
Ossiurn,  Fragilitas  Ossiuin,  Rickets,  Cancer, 
Syphilis,  Scrofula,  Gout,  Scurvy,  Mercurializatiou, 
&c.j  ill  predispose  to  the  occurrence  of  fractures. 

Exciting  causes. — The  exciting  causes  of  fracture 
ai-  mechanical  violence,  and  muscular  action 
Mechanical  violence,  may  act  either  directly  or  by 
.com  tor  stroke.  Muscular  action  most  frequently 
produces  fractures  of  the  patella,  calcaneum, 
humerus,  femur,  tibia,  and  olecranon  process  of 
the  ulna,  and  usually  implies  some  predisposition  to 
the  accident. 

General  Symptoms  of  Fracture. — The  most  com- 
mon and  important  signs  are  crepitus  ;  mobility  ; 
inability  of  the  parts  to  remain  in  position  when 
reduced  ;  pain  at  the  seat  of  fracture  ;  swelling  ; 
ecchymosis;  deformity  ;  and  inability  to  move  the 
limb.  The  examination  of  a  suspected  fracture 
should  be  made  as  early  and  as  quickly  as  possible, 
Chloroform  being  employed  if  there  is  the  least 
difficulty  in  regard  to  the  diagnosis. 

Treatment  of  Fractures. — The  treatment  of  frac- 
tures divides  itself,  naturally  into  two  processes, 
viz  :  reduction  and  retention.     Before    discussing 


344  TREATMENT   OF   FRACTURES. 

them  however,  it  will  not  be  amiss  to  consider  th< 
manner  in  which  a  man  who  has  sustained  a  seri 
ous  fracture  should  be  cared  for  in  advance  of  re 
gular  Surgical  treatment.     If  the  upper  member) 
are  broken,  the  patient,  as  a  general  thing,  can  tak< 
care  of  himself,  but  when  the  inferior  extremitie 
are  involved,  he  should  be  most  tenderly   and  in 
telligently  cared  for.     An  army  should  not  only  b<Ji 
well  supplied  with  litters,  but  a  permanent  detail 
should  also  be  made  from  each  regiment  of  somt 
of  its  bravest  and  strongest  men,  of  the  same  height; 
to  manage  them.     This  "  litter  corps  "  should  be 
under  the   immediate    direction    of  the   assistanl 
Surgeon, — to  be  instructed  by  him  before  the  fight^ 
and  directed  by  him  during   the   engagement,   so 
that  immediate  and  prt  per  attention  may  be  given 
the  wounded  in  the  first  moments  of  their  suffering 
and  danger.     The  advantages  of  this  arrangement 
are  two  fold  ;  it  prevents  those  who  are  uninjured 
from  leaving  the  ranks  under  the  excuse  of  taking 
care  of  the  wounded,  and  it  secures  prompt  assist- 
ance for  those   who  have  been   mutilated  by  the 
bullets  of  the  foe.     The  importance  of  prompt  an 
proper  assistance  is  particularly  apparent  in   con 
nexion  with  fractures  of  the  lower  extremities, — in 
as  much  as  it  precludes  farther  displacement  of  the 
fragments,  additional   injury   to  the   surrounding 
soft  parts,  a  more  serious  shock  to  the  system,  and 
unnecessary  pain  to  the  patient  himself:     This  sad 
picture  is  too  often  presented  on  the  field  of  battle, 
— the    wounded   are    put     astride    guns,   raised 
by   their  garments,  or  rolled    up    in  a   blauke 
and  dragged  to  a  place  of  safety.    When  a  prope; 


et 


TREATMENT  OF  FRACTURES.  345 

litter  cannot  be  had,  one  may  be  made  from  the 
blanket  of  a  soldier,  according  to  the  directions  of 
Chisolm.  Thus,  double  the  blanket  upon  itself; 
make  a  slit  through  the  end  corners  sufficiently 
arge  to  admit  the  barrel  of  a  musket ;  then  pass 
One  musket  through  the  fold  of  the  blanket  and 
another  through  the  slit  in  the  ends.  This  is  very 
defective,  and  if  the  door  or  blind  of  a  house  can 
be  procured,  it  may  be  substituted  with  advantage. 

The  easiest  way  to  raise  a  patient  and  place  him 
on  a  litter  is  this:  a  strong  man  standing  on  the 
sound  side,  puts  one  arm  round  the  patients  chest, 
and  the  other  hand  under  the  pelvis,  while  the 
j  atients  arm  is  placed  around  his  neck;  another 
assistant  should  support  the  pelvis,  and  a  second 
the  sound  limb  ;  iwo  others  sustain  the  broken  limb 
by  its  two  extremities,  taking  care  to  keep  it  in  the 
straight  ^.ositiou  ;  and  at  a  given  signal  the  patient 
is  raised  and  the  litter  slipped  under  him.  In  the 
same  way  lie  may  be  transfered  from  the  litter  to 
his  bed  or  from  one  bed  to  another.  The  patient 
having  been  carried  to  the  Infirmary  or  Hospital 
and  divested  of  his  clothes,  by  the  most  careful 
manipulation,  should  then  be  subjected  to  treat- 
ment. 

Reduction. — By  this  term  is  meant  the  bringing 
of  the  bones  in  proper  position.  It  is  accomplish- 
ed by  means  of  extension  and  counter  extension — 
forces  which  arc  employed  to  overcome  the  mus- 
cular contraction  by  which  the  fragments  are  kept 
in  an  unnatural  position,  or  by  l^laxing  the 
muscles,  and  at  the  same  time  so  manipulating  as 
to  bring  the  bones  properly  in  contact. 


346  TREATMENT  OF  FRACTURES.  - 

Retention. — The  bones  must  not  only  be  re- 
turned to  their  normal  relations  but  kept  there  by 
some  mechanical  contrivance.  This  object  is  ac- 
complished by  means  of  bandages  and  splints,  so 
adjusted  as  either  to  overcome  the  muscular  con- 
traction which  operates  as  the  separating  force,  or 
by  relaxing  the  muscles  exerting  that  force  upon 
the  fragments,  to  secure  their  retention  in  the  pro- 
per position.  This  whole  matter  will  be  more 
fully  explained  in  connexion  with  particular 
fractures. 

The  treatment  of  compound  and  complicated 
fractures  is  a  matter  of  particular  moment  to  the 
military  Surgeon,  especially  since  the  introduction 
of  conical  balls.  The  following  considerations 
should  serve  as  a  guide,  in  this  regard. 

1.  The  upper  limbs  manifest  a  much  greater 
vitality  and  resistance  to  injuries  than  the  lower, 
so  that  extensive  injury  to  their  bones  does  not 
necessarily  demand  amputation. 

2.  The  effect  of  a  conical  ball  upon  a  bone  is 
nearly  always  frightful,  either  comminuting  it  to 
a  great  extent,  or  splitting  it  longitudinally,  even 
when  the  soft  parts  are  but  slightly  injured. 

Whatever  then  may  be  the  indication  given  by 
the  external  wound,  it  is  the  duty  of  the  Surgeon, 
to  explore  it  thoroughly  and  without  delay,  for  the 
purpose  of  ascertaining  to  what  extent  the  bone  is 
injured,  and  of  deciding  upon  the  best  mode  of 
treatment. 

8.  The  question  to  be  decided  by  the  Surgeon  is 
not,  whether  it  is  possible  to  save  the  particular 
ease  before  him,  but  whether,  with  the  appliances . 


TREATMENT  OF   FRACTURES..  84? 

and  facilities  at  his  command  it  is  probable  that 
conservative  Surgery  would  ensure  a  favorable  re-  t 
suit.  In  civil  practice,  when  the  patient  can  be 
made  comfortable  and  is  surrounded  by  proper  * 
hygienic  conditions,  an  attempt  should  generally 
be  made  to  save  the  limb  ;  while  in  military  Sur- 
gery, where  discomfort  is  a  necessity  and  a  crowd- 
ed Hospital  teeming  with  the  putrescent  emana- 
tions of  filthy  wounds,  the  only  available  receptacle 
for  the  mutilated  victim,  then,  an  immediate  am- 
putation should  be  resorted  to. 

4.  The  fracture  of  a  bone  by  a  conical  ball  is  al- 
ways attended  with  frightful  sequela?.  Violent 
inflammation  is  speedily  developed  accompanied 
by  great  pain,  swelling  and  nervous  shock,  and 
followed  by  extensive  and  protracted  suppuration. 
The  ability  of  the  patient  to  stand  so  serious  a 
commotion  and  so  great  a  drain  should  likewise 
be  taken  into  the  account. 

5.  In  the  event  of  an  attempt  being  made  to  save 
the  limb,  the  Surgeon  should  proceed  to  remove 
all  loose  spicule  ;  to  smooth  off  the  sharp  ana  irre- 
gular ends  of  the  bones;  to  place  the  limb  in  the 
most  comfortable  and  convenient  position  ;  to  apply 
cold  water  or  iced  bladders  to  the  wound ;  to  pro- 
mote the  escape  of  pus ;  to  relieve  pain,  as  far  as 
practicable ;  to  support  the  strength  of  the  patient; 
and  when  the  inflammatory  action  has  subsided,  to 
apply  such  apparatus  as  is  best  calculated  to  pre_ 
vent  deformity. 

"When  union  does  not  take  place  within  a  rea- 
sonable time  it  may  be  facilitated  in  various  wayg. 
Thus  blister*,  caustic*,   electricity,  mercury,  tat 


348  TREATMENT   OF   FRACTURES. 

seton,  loops  of  wire,  acupuncture  needles,  abraiding 
or  removing  the  ends  of  the  bones,  and  subcu- 
taneous puncture  have  all  been  recommended  in 
this  connexion.  Brainard  employs  a  strong  me- 
tallic  perforator,  so  hardened  as  to  penetrate  the 
hardest  bone  or  ivory,  which  he  employs  in  the 
following  manner:  In  case  of  oblique  fracture 
or  one  with  overlapping,  the  skin  is  perforated 
with  the  instrument  at  such  a  point  as  to  enable  it 
to  be  carried  through  the  ends  of  the  fragments,  to 
wound  their  surfaces,  and  to  transfix  whatever  tissue 
may  be  placed  between  them.  After  having  trans- 
fixed them  in  one  direction  it  is  withdrawn  from 
the  bone,  but  not  from  the  skin,  its  direction 
changed  and  another  perforation  made,  and  this 
operation  is  repeated  as  often  as  may  be  desired. 
This  is  perhaps  the  best  of  all  the  plans  devised  to 
fulfill  the  indications  in  puch  eases.  In  conjunction 
with  it,  the  condition  of  the  patient's  general  health 
should  be  improved;  all  local  impediments  remov- 
ed; the  action  of  subjacent  tissues  promoted;  and 
the  patient  allowed  to  wTalk  about. 

Particular  Fractures. — Fracture  of  the  Cran:al 
Bones. — All  the  bones  of  the  head  may  be  fractured 
either  by  direct  violence  or  contre-coup.  These 
fractures  are  incomplete  or  comnlete,  either  vari- 
ety of  which  may  be  simple,  compound  or  compli- 
cated. 

Incomplete  Fracture. — The  forms  in  which  this 
lesion  presents  itself,  are,  (1.)  Cracks  or  fissures  of 
either  the  outer  or  inner  table,  there  being  no  de- 
pression or  separation  of  the  bones ;  and  (2)  de- 


FRACTURES  OF  CRANITU  349 

pressioh  of  the  bones  without  a  solution  of  their 
continuity. 

1.  These  cracks  or  fissures  may  be  associated 
either  with  mere  contusion  of  the  scalp,  or  with  a 
wound  of  it.  As  a  general  thing-  there  are  no  par- 
ticular signs  by  which  the  accident  can  be  distin- 
guished, though  there  may  be  associated  with  it, 
primarily,  concussion,  and  secondarily  compression 
or  inflammation  of  the  brain. 

2.  Depression  may  occur  in  young  children 
without  a  positive  division  of  the  structure  of  the 
bones,  having  the  same  associations  and  complica- 
tions as  were  referred  to  in  connexion  with  cracks 
or  fissures. 

Complete  Fractures. — This  variety  of  fracture 
may  present  itself  under  the  following  forms,  (1) 
fracture  without  depression  ;  (2)  fracture  with  de- 
pression ;  (3)  fracture  with  comminution  of  the 
bone  ;  (4)  fracture  with  a  removal  of  a  portion  of 
the  bone,  as  from  sword  cuts  ;  (5)  fractures  with 
depression  of  both  tables,  and  great  splintering  of 
the  internal  one,  as  from  bayonet  thrusts  or  even 
from  the  effects  of  musket  balls. 

1.  Simple  fracture  without  depression.  Both 
tablets  may  be  divided,  but  not  displaced,  in  con- 
nexion either  with  mere  contusions  of  the  scalp  or 
with  wounds  of  it,  as  the  result  of  direct  violence 
or  of  a  contre-coup.  This  accident  can  generally 
be  determined  by  running  the  finger  nail  or  the 
end  of  a  probe  over  the  exposed  surface  of  the 
wound  or  by  seeing  a  fissure  into  which  the  blood 
•inks.  The  most  serious  and  fatal  form  of  simple 
fracture  is  that  which  extends  through  the  base  of 
15 


350  FRACTURES   OF    CRANIUM. 

the  cranium,  and  in  a  majority  of  cases  is  the  re- 
sult of  counter  stroke.  The  strongest  presump- 
tive signs  of  the  existence  of  this  injury  are  the 
escape  of  blood  or  of  a  serous  fluid  from  the  ears 
and  nose.  If  the  bleeding  be  persistent  and  symp- 
toms of  serious  injury  to  the  brain  speedily  follow 
a  severe  blow  or  fall  upon  the  head,  the  occurrence, 
of  such  a  lesion  may  be  suspected. 

Even  simple  fracture  may  be  complicated  with 
concussion,  compression  or  inflammation  of  the 
brain. 

2.  Fracture  witli  depression.  Depression  may 
associate  itself  either  with  a  simple,  a  compound  or 
comminuted  fracture.  A  portion  of  the  bone  is 
found  depressed  or  driven  beyond  its  level  to"  a 
greater  or  less  extent  according  to  the  nature  of  the 
accident.  The  symptoms  or  signs  which  dis- 
tinguish this  accident  are  of  two  kinds  ;  those  which 
are  dependent  upon  the  injury  of  the  bone  and 
those  which  result  from  the  concomitant  pressure 
and  laceration  of  the  brain. 

As  a  general  thing  the  depression  can  be  felt, 
particularly  if  there  be  an  external  wound;  but  the 
surest  proof  of  the  occurrence  of  the  injury  consists 
in  the  immediate  manifestation  of  symptoms  of 
compression  of  the  brain,  and  the  subsequent 
development  of  the  characteristic  phenomena  ot 
cerebral  inflammation.  In  order  that  the  patho- 
logical difference  between  concussion  and  com- 
pression o  ithe  brain,  maybe  thoroughly  compre. 
bended,  the  essential  phenomena  of  each  are  here 
tabulated. 


FRACTIKKS  OF  CRANIUM. 


851 


on 


CONCUSSION. 

1.  The  symptoms  are  usual- 
ly immediate. 

2.  The  patient  can  be  made 
to  answer  questions  incohe- 
rently. 

3.  The  p  atient  can  still  hear 
see.  taste  and  feel. 

4.  Respiration  is  feeble  and 
noiseless. 

5.  The  pulse  is  weak,  trem- 
ulous, Intermittent  and  fre- 
quent. 

0.  There  is  nausia,  and  vom- 
iting. 

/ .    Bowels  are  relaxed. 

8.  Water  sometimes  flows 
from  the  bladder,  but  is  usual- 
ly voided  regularly. 

9.  There  is  no  paralysis  oi 
the  muscles. 

10.  The  pupils  are  irregular- 
ly contracted  or  dilated. 

1  1 .    The  brain  is  shaken. 

12.  The  surface  is  pale   and 

Cold. 

13.  The  pulse  prows  strong- 
er as  normal  condition  returns, 
reaction  and  fever  ensuing.. 

11.  The  symptoms  indicate 
a  condition  of  syncope. 


COMPRfiSSfoN. 

I.  The  symptoms  are  usual- 
ly delayed  for  a  few  moments. 

L>.  The  patient  cannot  be 
roused,  and  is  speechless. 

].  Special  sensation  is  des- 
troyed. 

4.  Respiration  slow,  labori- 
ous,   stertorous,  and  blowing. 

5.  The  pulse  is  slow  and 
full. 

6.  The  Stomach  is  quiet  and 
insensible  to  emetics. 

7.  The  bowels  are  const  ipa- 
ed. 

8.  The  blad  ler  is  paralysed, 
and  the  use  of  the  catheter  is 
necessary. 

9.  There  is  always  paralysis, 
and  on  the  opposite  side  from 
the  wound. 

10.  The  pupils  are  widely 
dilated. 

II.  The  brain  is  compressed. 

12.  The  surface  is  not  pale 
and  cold,  but  rather  the  re- 
verse. 

13.  The  pulse  grows  weaK- 
er  as  health  returns — collapse 
frequently  ensuts. 

14.  The  symptoms  indicate 
a  state  of  cerebral  apoplexy. 


Concussion  may  terminate  in  compression  in 
consequence  of  the  pouring  out  of  blood  from  the 
small  vessels  which  have  been  divided  by  the 
oscillation  of  the  brain,  after  reaction  lias  taken 
place;  while  either  of  these  conditions  may  even 
tuate  in  the  development  of  inflammatory  action, 
with  its  chat  acteristic  phenomena  and  terminations. 
Compression  may  be  caused  by  either  or  all  of  the 


352  FRACTURES    OF    CRANIUM.      ■ 

following  causes:   depressed   bono  ;   extravasated 

blood;  and  purulent  deposit — the  first  producing 
its  effects  immediately,  the  other  after  the  lapse  of 
some  little  time,  and  the  last,  at  a  more  remote 
period  in  the  history  of  the  case. 

3.  Fracture  with  comminution  of  the  bone. — The 
skull  is  frequently  the  seat  of  multiple  fractures. 
Either  from  the  abnormal  condition  of  the  bones  or 
the  peculiarity  of  the  injury,  it  often  happens  that 
the  bones  are  broken  into  a  number  of  fragments. 
Balls  usually  pa$s  through  the  bones  without 
splintering  them,  but  it  sometimes  occurs  that  the 
injurying  force  disseminates  itself,  producing  ex- 
tensive comminution  of  both  tablets. 

Under  these  circumstances  the  danger  is  from 
inflammation  of  the  brain  and  its  membranes ;  and 
from  fungus  of  the  brain.  There  may  be  depression 
with  its  usual  symptoms,  but,  as  there  is  extensive 
solution  of  the  bony  continuity,  the  fragments  are 
not  held  down  upon  the  surface  of  the  brain  by  any 
considerable  force,  and  not  unfrequently  rise  again 
to  their  original  level,  relieving  the  cerebral- sub- 
stance of  the  disasterous  consequences  of  their 
presence.  Many  of  the  detached  fragments  become 
necrosed,  dying  slowly  and  endangering  the  deli- 
cate structures  beneath  them  until  the  work  of 
elimination  has  been  perfected.  The  substance  of 
the  brain  may  be  injured  contemporaneously  with 
the  fracture  of  the  bone,  causing  a  speedy  extra- 
vasation of  blood,  and  the  development  of  cerebral 
inflammation. 

4.  Removal  of  a  portion  of  the  bone.  Portions 
of  tile  skull  are  sometimes  carried  away  by  sword 


FRACTURES  OF  CRANIUM.  353 

cuts,  which  it' promptly  reapplied  will  adhere  with- 
out unfavorable  consequences;  There  is  always 
danger  of  hernia  and  inflammation  of  the  brain; 

5.  Fractures  with  splintering  of  the  internal 
table.  These  accidents  result  from  bayonet,  dirk 
and  ball  wounds,  and  are  of  the  greatest  interesl  to 
the  Surgeon.  They  are  always  complicated  with 
injury  to  the  cerebral  surface,  and  frequently,  by 
the  actual  presence  of  a  foreign  body  in  the  wound. 
While  connected  with  the  General  Hospital  at; 
Charlottesville,  Va.,  it  fell  to  my  lot  to  make  an 
autopsy  of  a  soldier  who  had  died  from  the  effects 
of  a  gunshot  wound  of  the  head.  A  conical  ball 
had  entered  the  left  parietal  bone  about  one  inch 
from  the  sagittal  suture,  making  a  smooth,  round 
hole  in  the  external  tablet,  and  imbedding  itself  in 
the  substance  of  the  brain.  The  patient  was  at- 
tacked with  violent  convulsions  on  the  fourteenth 
day  subsequent  to  the  receipt  of  the  injury,  and 
died  comatose  in  a  few  hours  afterwards.  Upon 
removing  the  upper  half  of  the  cranium,  a  large 
abscess  was  found  immediately  beneath  the  orifice 
in  the  bone,  containing  the  ball  and  a  quantityof 
puss;  and  the  whole  dura  mater  was  injected  with 
b  ood ;  while  at  the  point  of  the  inner  tablet 
through  which  the  missile  had  passed,  was  a  round 
hole,  from  the  entire  circumference  oi  which  there 
radiated  numerous  spicuhv  which  had  penetrate 
the  membranes  of  the  brain  and  acted  as  foreign 
and  offending  bodies  to  them,  as  well  as  to  the  de- 
cate  structure  beneath. 

This  case  is  but  a   type  of  hundreds    of  others, 
and  throws  much  light  upon  the  pathological  con- 


354  FRACTURES  OF  CRANIUM. 

ditions  which  such  injuries  develop.  Whatever 
may  be  said  of  the  trephine,  it  is  plain  that  it  might 
have  been  employed  to  advantage  in  this  con- 
nexion, for  the  following  reasons. 

1.  It  would  have  ensured  the  removal  of  the  ball. 

2.  It  would  have  accomplished  the  evacuation 
of  the  pus. 

3.  It  would  have  removed  the  spieulse  which 
were  sources  of  inflammatory  disturbance  to  the 
cerebral  substance.  As  a  matter  of  curiosity,  an 
attempt  was  made  to  remove  the  spicule  which 
radiated  from  the  circumference  of  the  inner  orifice, 
in  order  to  determine  to  some  extent  how  far  such 
a  procedure  could  be  regarded  as  "meddlesome 
Surgery"  in  actual  practice.  By  means  of  a  de- 
licate pair  of  forceps,  and  with  a  little  care,  all  of 
them  were  speedily  removed  through  the  external 
orifice  of  the  wound — the  whole  thing  being  ac- 
complished with  so  much  facility  as  to  convince  ail 
present  of  the  practicability  and  propriety  of  such 
an  operation  under  any  circumstances,  provided 
the  opening  be  large  enough. 

When  the  fracture  has  been  occasioned  by 
puncture  with  a  sharp  instrument,  the  legion  should 
oe  esteemed  one  of  importance  and  gravity. 

The  danger  is  from  cerebral  inflammation,  which 
ensues  within  a  few  days,  and  generally  destroys 
life.  This  accident  can  always  be  recognized  by 
digital  compression  aided  by  a  probe,  particularly 
if  the  previous  history  of  the  case  can  be  obtained. 

Treatment. — In  fissures  and  simple  fractures 
without  local  or  general   complications,    keep  the 


FRACTURES   OF   CRANIUM.  oo5 

patient  quiet ;  give  a  mild  purgative  ;   and   apply 
cold  applications  to  the  seat  of  injury. 

Guthrie  has  wisely  remarked  that  ''injuries  of 
the  head  affecting  the  brain  are  difficult  of  distincj 
tion,  doubtful*  in  character,  treacherous  in  their 
course,  and  for  the  most  part  fatal  in  their  results:  " 
while  Macleod  declares  that,  of  all  the  accidents 
met  with  in  the  field,  these  are  the  most  serious, 
both  directly  and  indirectly — the  must  confused  in 
their  manifestations  and  the  least  determined  in 
their  treatment."  In  the  truth  of  these  observa- 
tions all  military  Surgeons  must  agree,  since  this 
elass  of  injuries  still  constitute  the  opprobrium  of 
their  art  notwithstanding  the  researches  and  labors 
o\'  its  ablest  masters. 

A  remarkable  disparity  presents  itself  between 
the  injury  inflicted  and  the  effects  prod  need  by  it. 
Thus,  in  many  instances  wounds,  apparently  of  the 
most  trivial  character,  are  followed  by  the  gravest 
results :  while  in  other  cases,  extensive  comminu- 
tion of  the  bones  of  the  cranium,  together  with 
considerable  destruction  of  the  cerebral  substances 
itself,  produces  but  an  inconsiderable  disturbance 
in  the  economy.  As  regards  the  prognosis  in  this 
connexion,  the  rule  is  to  hope  for  everything,  what- 
ever the  nature  ot  the  injury,  but  to  be  confident 
of  nothing,  since  recovery  may  follow  the  gravest 
accident  and  death  ensue  upon  the  slight- 

Cunningham  relates  the  case  of  a  boy  who  lived 
for  twenty  four  days  with  the  breech  of  a  pistol 
\\  eighing  nine  drachms  lying  on  the  tentorium  and 
resting  against  tin'  occipital  bone.  ()'( lallaghan 
has  recorded  the  case  of  an  officer  who  lived  seven 


356  FRACTURES  OF  CRANIUM. 

years  with  the  breech  of  a  fowling  piece,  weighing 
three  ounces,  lodged  in  the  forehead  and  in  contact 
with  the  brain.  Ellerslie  Wallace,  gives  the  case 
of  a  girl  who  rapidly  recovered  without  an  unto 
ward  symptom,  from  a  wound  inflicted  by  a  cir- 
cular saw,  four  inches  and  a  quarter  in  length,  by 
one  sixth  of  an  inch  in  width,  extending  across  the 
skull,  wounding  the  brain,  and  dividing  the  longi- 
tudinal sinus.  Henuen  states  that  he  has  seen  five 
cases  in  which  bullets  were  lodged  in  the  brain 
without  proving  immediately  fatal;  and  also  me  - 
tions  an  instance  in  which  the  bone  was  depressed 
in  a  "funnel  shape  "  to  the  extent  of  an  inch  and  a 
half,  without  producing  an  unfavorable  symptom. 
The  most  remarkable  case  is  that  reported  by 
Bigelow,  in*  which,  by  the  premature  explosion  of 
a  blast,  a  tamping-iron,  three  feet  four  inches  in 
length,  one  and  a  quarter  inches  in  diameter,  and 
weighing  thirteen  and  a  quarter  pounds,  traversed 
the  cranium  from  the  angle  of  the  lower  jaw  on 
one  side  to  the  centre  of  the  frontal  bone  above, 
near  the  sagittal  suture.  From  this  extraordinary 
lesion  the  patient  recovered,  with  the  loss  only  of 
the  sight  of  the  injured  eye. 

The  effects  of  an  injury  inflicted  by  balls  strik- 
ing the  skull  will  depend  upon  the  following  cir- 
cumstances : 

1.  Upon  the  manner  in  which  the  ball  strikes 
the  skull.  "When  the  direction  of  the  projectile  is 
very  oblique,  and  its  force  considerably  exhausted, 
the  injury  inflicted  may  be  only  a  slight  contusion 
of  the  soft  parts  or  of  the  bone.  When  the  force 
is  greater,  the  scalp  may  be  extensively  lacerated 


FRACTURES    OK    CRANH  M  .  •'••« 

and  the  bone  bruised  and   broken    through  out  its 

whole  extent,  or  through  one  oi  its  tables  only,  and 
the  cerebral  substance  beneath  considerably  in- 
jured. Under  these  circumstances  concussion  is 
likely  to  ensue,  terminating,  it  may  be,  in  "  en- 
cephalic inflammation  and  compression  from  ef- 
fusion." 

Again,  a  shot  which  merely  grazes  the  head  and 
"brushes"  over  the  skull,  may  completely  smash 
the  bones  of  the  cranium  without  injuring  the 
scalp,  or  by  only  opening  the  veins  immediately 
beneath  the  skull,  produce  instant  death. 

2.  Upon  the  character  of  the  ball. — Conieal  halls 
crush  through  both  tables,  with  great  violence, 
producing  orifices  of  equal  seize,  comminuting  the 
bone  extensively,  and  carrying  the  fragments  de<  p 
into  the  substance  of  the  brain.  Wound  halls,  on 
the  contrary,  neither  produce  so"great  a  destruction 
of  the  outer  table,  nor  SO  extensive  and  minute  a 
comminution  of  the  bones. 

The  greater  splintering  of  the  inner  than  of  the 
outer  table,  which  usually  occurs  in  wounds  of  the 
head,  is  explicable  by  the  fact  that  the  latterisbet 
ter  supported  by  the  parts  beneath  it,  and  that  the 
momentum  ot  the  ball  is  necessarily  diminished  in 
passing  through  them.  The  same  principles  inter- 
pret tho  difference  between  the  wounds  of  en- 
trance and  exit  in  the  soft  parts,  fii this  connexion 
it  may  be  well  to  sum  up  the  differences  by  which 
the  wounds  of  entrance  and  exit,  in  the  soft  parts, 
can  be  distinguished. 
15b 


358         FRACTURES  OP  CRANIUM. 


THE  WOUND  OF  ENTRANCE  IS  : 

1.  Regular  and  inverted. 

2.  White,  depressed,  and  ad- 
herent to  the  underlying  parts. 

3.  Characterized  by  positive 
loss  of  substance,  and  some- 
times by  the  presence  of  foreign 
substances,  as  clothing,  &c. 

4.  More  disposed  to  bleed 
than  the  wound  of  exit. 


THE  WOUND  OF  EXIT  IS  : 

1.  Irregular  and  everted 

2.  More  discolored, but  indis 
tinct  and  not  adherent. 

3.  Characterized  by  a  flap 
like  tearing,  and  by  no  compli- 
cation of  foreign  substances, 
&c. 

4.  Lees  disposed  to  bleed 
than  the  wound  of  entrance. 


These  differences  are  by  no  means  constant  and 
invariable.  The  speed  of  the  ball,  the  mode  of 
impingement,  the  nature  of  the  wounded  structure^ 
and  the  distance  at  which  the  gun  is  fired,  exercise 
a  material  influence  in  determining  and  modifying 
their  character. 

The  great  velocity  and  peculiar  motion  of  coni- 
cal balls  impress  upon  wounds  a  character  materi- 
ally different  from  that  caused  by  round  balls. — 
When  the  distance  is  short,  and  the  parts  fleshy, 
there  is  less  laceration  of  the  soft  parts  ;  but  "  when 
the  range  is  greater  and  the  part  struck  bony,  the 
tearing  especially  at  the  place  of  exit  is  greatly 
more  marked." 

They,  also,  may  lodge  beneath  the  outer  table 
without  penetrating  the  cranium,  or,  after  striking 
against  a  bony  angle  or  projection,  split  into  two 
fragments,!  one  entering  the  skull  and  the  other 
flying  off ;  and  again,  in  some  instances,  they  have 
been  known  to  be  deflected  from  their  course,  af- 


3  Maclcod,  in  speaking  of  this  subject,  refers  to  the  fact  that  round 
hulls  frequently  split,  nut  remarks  that  he  does  not  behove  that  "  the 
conical  ball  wltn  its  immense  foree  of  propulsion  could  he  so  split." 
In  the,  clothes'ofa  friend  of  the  author,  who  was  killed  at  Malvern, 
one  half  of  a  conical  hall  was  found,  tin:  other  half  having  penetruted 
the  body  and  produced  his  death. 


TRACTURES   OF   CRANIUM.  o59 

tor  dividing  the  sculp,  and,  without  fracturing  the 
bones,  to  make  the  entire  circuit  of  the  head. 

3.  Upon  the  part  struck. — Wounds  of  the  side 
of  the  head,  especially  anterior  to  the  ear,  arc  the 
most  dangerous, — thus,  a  descending  scale  will 
givejthe  following  order:  the  fore  part,  thievertex, 
and  the  upper  part  of  the  occipital  region.  Wounds 
of  the  base  of  the  brain,  especially  ot  the  pons  and 
medulla,  are  necessarily  and  immediately  fatal. 

When  large  vessels  are  divided,  especially  the 
sinuses,  death  takes  place  as  a  matter  of  nece's? 
siry. 

1.  rpon  the  age  anil  temperament,  &c,  of  the 
patient. — In  the  young  the  same  danger  is  not  to 
be  apprehended  from  injuries  of  the  head  as  in 
adults. 

It  can  also  be  readily  understood  how  the  tem- 
perament, and  the  general  surroundings  of  the  suf- 
ferer exert  an  influence  updn  the  prognosis,  by  in- 
creasing or  diminishing  the  tendency  to  control 
inflammation,  and  assisting  or  interfering  with  the 
proper  treatment  of  the  ease. 

Shell  wounds,  though  comparatively  rare,  pro- 
duce the  most  fearful  injuries  and  speedily  termi- 
nate in  death. 

For  all  wounds  of  the  scalp,  danger  from  erysip- 
elas is  to  be  apprehended. 

btXtiswcs. 
Macleod  reports  680  cases    "f  mere  contusion, 
with  s  deaths  :  1 35 -cases  di  fracture  with  depres- 
sion, with  7o*  deaths:  67  cases  of  penetration,  with 
67  deaths ;  and  in  cfcses   of  perforation    with 


360  FRACTURES  OJF  CRANIUM. 

deaths.  Alcock  reports  28  cases  of  fracture  with 
gunshot  wounds,  with  22  deaths.  Mauiere  reports 
10  penetrating  wounds,  with  10  deaths.  Lente  re- 
ports 128  cases  of  fracture  of  the  skull,  with  106 
deaths.  Stromyer  reports  41  cases  of  gunshot  frac- 
tures of  the  skull,  with  only  7  deaths. 

Treatment. — The  treatment  of  fractures  of  the 
skull  has  a  direct  reference  either  to  the  existence 
or  to  the  possible  development  of  the  various  com- 
plication, which  have  just  been  referred  to.  The 
following  general  plan  will  be  found  most  availa- 
ble, if  carried  out  either  in  part  or  wholly,  according 
to  the  necessities  of  the  case. 

Control  the  hemorrhage  ;  remove,  at  once,  all 
foreign  bodies,  which  can  be  readily  reached — such 
as  balls,  spicula?,  wadding,  dirt,  &c. ;  wash  and 
bring  the  edges  of  the  wound  gently  together ; 
treat  symptoms  of  compression,  if  present,  by 
placing  the  patient  in  the  recumbent  position  with 
his  head  lower  than  his  body,  using  external  stimu- 
lation, if  the  pulse  fails  ;  when  reaction  is  establish- 
ed, or  when  there  are  symptoms  of  compression  or 
inflammation  from  the  start,  bleed  and  purge  freely, 
use  cold  applications  to  the  head,  enjoin  perfect  rest, 
give  repose  to  the  special  senses,  as  far  as  practica- 
ble, enforce  the  lowest  diet ;  and,  finally,  when, 
all  other  means  have  failed,  and  symptoms  of  cere- 
bral compression,  inflammation,  effusion  of  blood, 
or  the  formation  of  pus  exist  to  such  an  extent  as  to 
render  the  diagnosis  a  matter  of  no  difficulty,  re- 
sort to  the  trephine  and  give  the  patient  the  last 
chance  for  his  life. 

It  is  true  that  the  weight  of  authority,  so  far  a* 


FRACTURES  OF  CRANIUM.  361 

writers  on  modern  Surgery  arc  concerned,  prepon- 
derates against  such  an  employment  of  this  instru- 
ment; but,  after  a  due  consideration  of  their  argu- 
ments and  statistics,  an  attentive  study  of  the  works 
of  the  older  masters,  and  no  little  personal  obser- 
vation and  experience,  the  advice  in  regard  to  this 
instrument,  is  freely  given  with  the  full  assurance 
of  its  reliability  and  propriety  in  this  connexion.  In 
some  instances  of  compound  fracture  with  depres- 
sion, or  with  the  penetration  of  a  foreign  body  in- 
to the  substance  of  the  brain,  the  trephine  may  ho 
immediately  employed,  but  this  is  not  the  general 
rule,  as  has  been  previously  stated.  Neither  chlo- 
roform nor  ether  should  be  used  in  this  operation 
for  fear  of  inducing  inflammation  of  the  brain. 

Portions  of  the  skull  sliced  off"  by  the  sabre  or 
sword  should  be  replaced  and  secured  by  wire  su- 
tures, even  if  they  are  attached  by  small  shreds  of 
the  scalp. 

In  all  scalp  wounds,  however  caused,  avoid  the 
use  of  sutures,  and  guard  against  the  development 
ot  erysipelas.  In  simple  divisions  of  the  scalp, 
from  blows  or  cuts,  the  edges  of  the  wound  may  be 
readily  kept  in  apposition  by  crossing  the  hairs  at 
different  points  and  binding  them  by  means  of  small 
shot. 

Hernia  cerebri  should  be  treated  in  its  earlier 
stages  by  well  condueted,  systematic  compression. 
Pressure  should  be  made  with  a  piece  of  sheet  lead, 
a  compress  and  a  roller  changed  as  often  as  may 
be  necessary  to  ensure  firmness  and  cleanliness. 
As  the  mass  recedes,  the    compress    is   gradually 


362  FRACTURES   OF   FACIAL    BONES. 

pushed  into  an  osseous  opening  until  it  is  reduced 
to  the  level  of  the  brain.  • 

If  by  any  accident  the  protrusion  has  attained  to 
considerable  bulk,  the  proper  plan  is  to  exercise  all 
that  is  accessible  or  to  destroy  it  with  Vienna  paste 
or  the  actual  cautery. 

Fracture  of  the  Bones  of  the  Face. — The  hones 
of  the  face  which  present  the  greatest  importance 
in  this  connexion  are  the  malar,  the  nasal  and  the 
upper  and  lower  maxillary. 

Frmtures  of  Malar  Bone 

Causes. — Direct  violence — such  as  blows  or  falls. 

Symptoms. — Depression  of  the  bone,  tilting  up- 
wards of  orbital  plate,  and  protrusion  of  the  eye. 

Treatment. — Push  the  bone  into  position  by 
carrying  the  finger  through  the  mouth  into  the 
temporal  fossa. 

Fracture  of  the  Nose. — Causes. — Falls  or  blows. 

Symptoms. — Depression  of  the  bone,  and  inter- 
ference with  nasal  breathing, — or  lateral  devia- 
tion of  the  nose. 

Treatment. — Insert  the  finger  or  some  suitable 
instrument  and  elevate  the  bone.  In  lateral  de- 
viations restore  the  nose  to  its  proper  position,  and 
keep  it  there  by  means  of  adhesive  strips. 

iracture  of  Upper  Maxillary  Bone. — Causes. — 
Falls,  blows  and  wounds. 

Symptoms. — Dispjacenient,  deformity,  and  sepa- 
ration of  the  bones. 

Treatment.. — Mould  the  bones  into  shape;  save 
every  osseous  fragment;  and  keep  parts  in  appo- 
sition by  means  of  adhesive  plaster. 


FRACTURES   OF   LOWER   JAW.  363 

Fracture  of  Inferior  Mi  ciliary  Bone — This  bone 
may  be  fractured  tltrough  its  body,  angle  or  ramus 
and  condyles. 

Causes. — Direct  blows,  kicks  From  horses,  sword 
cuts,  bullets,  &c. 

Symptoms. — Fractures  of  the  body  are  character- 
ized by  displacement,  mobility,  crepitus  and  pain. 
The  displacement  is  greater  in  proportion  as  tbe 
fracture  is  nearer  the  symphysis,  and  less  as  it  ap- 
proaches the  angle. 

Salivation  and  swelling  of  the  sub-maxilla  rv 
gland,  together  with  difficulty  of  speech  and  deglu- 
tition are  soon  developed.  A  fracture  of  the  ramus 
may  be  distinguished  by  a  grating  noise  at  the  seat 
of  the  injury  and  great  pain  about  the  ear. 

A  fracture  ot  the  neck  maybe  determined  by 
crepitation  in  moving  the  jaw,  preternatural  mo- 
bility in  front  of  the  ear  and  the  dragging  forward 
of  the  bone  by  the  external  pterygoid  muscle. 
Fracture  of  the  condyle  may  be  readily  distin- 
guished in  the  same  way.  In  connexion  with  com- 
pound fractures  of  this  bone  and  the  bones  of  the 
face  generally  ;  hemorrhage,  paralysis — from  di- 
vision of  the  branches  of  the  facial  nerve — inflam- 
mation, and  constitutional  irritation  ;  produced  by 
swallowing  the  secretions  from  the  wound,  are 
likely  to  occur. 

Treatment. — In  cases  of  simple  fracture,  seat  the 
patient  upon  a  chair  ;  support  his  head  upon  the 
breast  of  an  assistant  and  let  it  be  firmly  held  ; 
pass  the  fingers  along  the  base  of  the  jaw.  or  the 
fractured  portion  of  the  bone;  mould  the  parts 
into  proper  shape  :  close  the  mouth,  take  care  that 


3t>4  FRACTURES   OF   LOWER   JAW. 

the  lower  teeth  rest  firmly  against  the  upper;  then 
adapt  a  piece  of  paste  hoard  of*  felt  wet  with  hot 
water  to  the  base  and  sides  of  the  jaw  ;  and  finally 
apply  either  Gibson's  or  Barton's  bandages,  so  as 
to  press  the  lower  jaw  firmly  against  the  other. 
If  the  bone  be  comminuted  and  the  teeth  forced 
from  their  socket,  the  latter  should  be  returned, 
and  secured  to  the  sound  ones  by  silver  wire. 

In  compound  fractures  care  should  be  taken  to 
preserve  as  much  of  the  bone  as  possible,  to  keep 
the  fragments  in  apposition,  to  arrest  hemorrhage 
by  compressing  or  ligating  either  the  external 
carotid  or  the  facial  artery,  to  counteract  the  dis- 
turbing agency  of  muscles  by  compresses,  band- 
ages and  adhesive  strips,  and  to  see  that  the  secre- 
tions from  the  wound  are  not  swallowed.  Inflam- 
mation should  be  treated  \n  general  principles- 
Fluid  food  must  be  administered  for  several  weeks 
when  semi-solid  nourishment  may  be   substituted. 

Fractures  of  the  Bones  of  the  Trunk. — Frac- 
ture of  the  Clavicle.— Causes. — Falls,  blows,  wounds 
from  sabres,  bullets,  shells,  &c. 

Varieties. — Eractures  of  the  clavicle  may  be  sim- 
ple, compound,  comminuted,  complicated,  unilat- 
eral, bilateral,  transverse  or  oblique.  The  usual 
seat  of  fracture  is. at  the  middle  of  the  bone  where 
it  is  weakest. 

Symptoms. — Sunken  appearance  of  the  shoulder; 
shoulder  drawn  downwards,  inwards  and  forward 
by  the  weight  of  the  limb  and   the   action    of  the 
deltoid,  subclavius  and  pectorial  muscles;  inclina 
tion  of  head  and  trunk  to   affected    side;  impossi 


FRACTURES   01   CLAVICLE,  365 

bility  of  rotating  the  arm  by  carrying  hand  to  the 
face  ;  crepitation,  elicited  by  pushing  the  shoulder 
upwards,  outwards  and  backwards  ;  separation  of 
the  fragments,  the  outer  being  drawn  downwards 
inwards  and  forwards,  and  the  inner  fragment, 
slightly  upwards  by  the  stern o-cleido-mastoid  mus- 
cle. 

Ireaiment. — The  great  indication  is  to  carry  the 
shoulder  upwards,  outwards  and  backwards,  until 
the  outer  fragment  reaches  the  level  of  the  inner 
fragment,  and  to  retain  it  there.  The  reduction 
of  the  fracture  may  be  readily  accomplished,  but 
retention  is  more  difficult.  The  simplest  and  most 
effectual  method  of  keeping  the  fragments  in  ap- 
position, is  to  place  a  pad  in  the  axilla  ;  to  bring 
the  elbow  against  the  antero-lateral  aspect  of  the 
chest  and  to  place  the  fore-arm  against  the  front ; 
to  carry  the  fingers  across  the  opposite  clavicle ;  and 
then  to  apply  adhesive  strips,  reaching  around 
the  limb  and  shoulders,  and  binding  the  arm 
down  to  the  chest.  If  this  is  not  sufficient  the 
apparatus  of  Velpeau,  Fox,  Levis  or  Dugas  may 
be  employed.  Compound,  comminuted  and  com- 
plicated fractures  should  be  treated  on  general 
principles,  remembering  that  the  great  indication 
is  to  carry  the  shoulder  upwards,  backwards  and 
outwards  and  to  retain  it  there  until  union  has 
taken  place. 

Fractures  of  the  Scajmla. — These  are  of  rare  oc- 
currence, especially  in  civil  Surgery.  When  the 
(u-romioii  process  is  broken  the  accident  generally 
produced  by  violence  applied  to  the  upper  and  outer 
parts  of  the  should,  r. 


366  FRADTURES    OP  SCAPULA. 

Symptoms. — Tlie  shoulder  loses  its  rotundity; 
the  fractured  portion  is  drawn  downwards  and  for* 
wards  by  the  action  of  the  deltoid  muscle ;  the 
fragments  rests  upon  the  front  and  upper  part  of 
the  head  of  the  humerus  ;  and  the  limb  is  movable  ; 
while  the  signs  ot  the  accident  are  effaced  when 
the  arm  is  elevated. 

Treatment. — The  indication  is  to  relax  the  del- 
toid muscle  by  carrying  the  arm  forward  across 
the  chest,  and  by  raising  the  elbow  up  so  that  the 
head  of  the  humerus  may  press  against  the  acro- 
mion process.  The  same  apparatus  as  for  frac- 
tured clavicle  may  bo  used,  dispensing  with  the 
axillary  pad. 

When  the  Coracoid  process  is  broken — which  is 
a  rare  accident — the  fragment  is  carried  inward 
and  downwards,  by  the  conjoined  action  of  the  pec- 
toralis  major  and  the  coraco-brachialis  muscles. 

Treatment. — Flex  the  fore  arm  and  carry  the 
arm  forwards  across  the  chest ;  place  a  pad  in  the 
axilla;  and  push  the  humerus  upwards.  Retain 
the  arm  in  position  by  means  of  adhesive  strips. 

When  the  body  of  the  bone  is  broken,  there  is 
no  displacement.  The  bone  should  be  steadied  by 
applying  pads  and  keeping  them  in  position  by 
means  of  adhesive  strips  or  rollers  carried  around 
the  chest. 

Fractures  of  the  Ribs. — Causes.  Violence  of  all 
kinds,  such  as  falls,  blows,  gunshot  wounds,  and 
muscular  action,  &c.  The  central  ribs  being  more 
exposed  are  most  frequently  broken. 

Symptoms.—  Displacement  of  fragments  with  crep- 
itation- such  as  can  be  felt  with  the  hands  when  the 


FRATURES"  OF  THE  Rl  •  367 

patient  coughs;  a  peculiar  cracking  noise  follow- 
ing a  deep  inspiration  ;  pain  at  the  seat  of  injury, 
increased  by  the  respiratory  efforts;  spitting  of 
blood,  together  with  pleuritic  and  pneumonic 
symptoms,  dyspnoea  and  emphysema,  if  either 
fragments  or  spieuhe  have  been  pushed  inwards; 
andcopiusexteanal  hemorrhage  when,  the  intercostal 
artery  has  been  divided.  It  not  unfrequently  hap- 
pens in  compound  fractures  of  the  ribs  that  largo 
spicuhvof  bone  are  driven  deeply  into  the  parenchy- 
ma of  the  lungs,  causing  violent  inflammation,  he- 
morrhage, escape  of  air  into  the  cavity  of  the:  pleura, 
disappearance  of  the  respiratory  murmur  unusual 
resonance,  &c,  followed  either  by  speedy  death  or 
protracted  suppuration.  Again,  a  spent  ball  may 
impinge  with  some  violence  against  a  rib,  not 
fracturing  the  bone  but  seriously  implicating  the 
delicate  structures  beneath  it. 

Ireatmcnt. — In  simple  fracture  without  serious 
displacement,  encircle  the  chest  with  a  broad  band- 
age or  strip  of  adhesive  plaster,  so  that  the  inter- 
costal muscles  may  be  put  in  motion  as  little  as 
possible  in  connexion  with  the  respiratory  func- 
tion. If  there  be  outward  displacement  the  same 
apparatus,  with  the  addition  of  compresses  may 
be  employed.  If  the  displacement  be  inwards  it 
should  not  be  interfered  with,  unless  complicated 
by  serious  symptoms  connecting  themselves  with 
the  lungs  or  pleura.  In  such  a  contingency,  after 
failing  to  afford  relief  to  the  patient  by  a  proper 
use  of  pressure  and  antiphlogistic  remedies,  the 
fragment  may  be  raised  by  mechanical  means.  H 
there  be  dangerous  hemorrhage  from  an  iptercos- 


368  FRACTURES   OF   THE   RIBS. 

tal  artery  it  may  be   compressed  against  a   rib  or 
drawn  out  and  tied. 

In  compound  fractures  the  depressed  portions' 
should  be  elevated;  the  spieuhe  and  foreign  bodies 
removed ;  the  pain,  cough,  &c,  incident  to  pul- 
monary lesious  treated  with  opium  administered 
in  large  doses  ;  hemorrhage  arrested  by  copious 
bleeding  from  the  arm,  so  as  to  produce  syncope 
and  induce  the  formation  of  clots  in  the  divided 
vessels  ;  the  wound  closed  as  soon  as  hemorrhage 
ceases;  the  patient  placed  upon  the  wounded  sidej 
so  as  to  promote  adhesion  and  facilitate  the  escape 
of  all  fluids  ;  digitalis  or  veratrum  administered  to 
control  the  circulation ;  inflammation  treated  on 
general  principles;  and  pus  or  air  evacuated,  if  it 
forms  in  sufficient  quantity  to  embarrass  the  circu- 
lation seriously.  If  there  be  the  serious  dyspnoea 
the  bandage  should  not  be  applied;  and  in  exam- 
ining the  wound,  the  finger  instead  of  the  probe 
should  be  employed,  lest  the  delicate  tissue  of  the 
lung  be  more  seriously  irritated.  When  inflam- 
mation of  the  lung  and  pleura  supervene  upon 
blows  which  do  not  fracture  the  rib,  opium  should 
be  freely  administered,  and  the  symptoms  treated 
on  general  principles. 

In  penetrating  wounds  of  the  lung  the  danger  is 
primarily  from  hemorrhage  and  collaps  and  secon- 
darily from  inflammation  and  its  products.  Dis- 
tinct plans  of  treatment  are  consequently  demand- 
ed at  different  periods  in  the  history  of  the  case  : 


+  In  wounds  from  stabs  this  rule  should  be  rigidly  adhered  to,  but 
in  gun  shot  wounds  the  patient  may  )>e  allowed  to  assume  the  poei- 
tion  most  agreeable  to  him. 


n;  VCTUBE8   Ofl   THE    RIBS.  369 

1.  The  employment  of  means  for   arresting  the 

How  of  blood — such  as  venesection,  opium,  &c. 

2.  The  employment  of  such  remedies  as  arc  re- 
quired to  arrest  inflammatory  reaction,  or  to  guard 
the  system  against  the  deleterious  effects  of  the 
products  of  that  process. 

If  venesection  be  attempted,  the  patient  should 
he  placed  in  the  ereel  position  and  a  large  opening 
made,  so  that  syncope  may  he  as  speedily  produced 
as  possible.  The  question  of  the  propriety  of  bleed- 
ing is  one  which  frequently  exercises  all  the  judg- 
ment at  the  command  of  the  Surgeon,  for  though 
venesection  is  tin  remedy  when  properly  employed, 
it  s  far  from  being  of  universal  application.  The 
following  circumstances  may  be  regarded  as  fur- 
nishing contra-indications  to  the  employment  of 
the  lancet  in  wounds  of  the  lung. 

1.  "When  a  considerable  time  has  elapsed  after 
the  receipt  of  the  wound,  and  a  large  amount  of 
blood  has  been  lost. 

2.  When  the  patient  is  weak  and  amende  in 
consequeuce  of  the  debilitating  influences  incident 
to  the  regime  of  camps  and  hospitals. 

3.  When  the  patient  has  been  debilitated  by 
previous  disease  Or  wounds. 

4.  When  the  large  vessels  leading  to  or  from 
the  heart  are  severed. 

5.  When  the  patient  has  received  other  wounds 
of  a  serious  charai 

6.  When  the  nervous  shock  incident  to  the 
wound  is  overwhelming. 

7.  When  the  erect  posture  cannot  be  borne. 

8.  When  proper  subsequent  treatment  is  impos- 


370  FRACTURES  OF  THE  RIBS. 

sible  as  in  hurried  marches,  hasty  retreats,  want  of 
the  means  of  transportation,  the  impossibility  of 
securing  reliable  and  continuous  surgical  assis- 
tance, &c. 

9.  When  the  patient  is  manifestly  in  articulo 
mortis. 

Wounds  of  the  lung  are  far  from  being  so  fatal 
as  might  be  supposed  in.  advance.  Numerous 
cases  have  come  under  my  own  observation,  during 
the  present  war,  in  which  rapid  recoveries  have 
followed  the  most  severe  penetrating  wounds  of 
this  delicate  organ.  The  experience  of  Confeder- 
ate Surgeons  will  confirm  the  assertion  that  unless 
death  speedily  results  from  hemorrhage  and  col- 
lapse a  favorable  prognosis  may  be  formed  in  a 
majority  of  such  case,c. 

STATISTICS. 

Reported  l>y  Maclcod,  122  cases.  9S  deaths. 

"             Legouest,  6     "                  3       " 

"    i          Guthrie,  106    "  53      " 

«|             Meniere,  29    "                 'J      " 

Fracture  of  the  Pelvis. — Causes. — Great  violence 
and  gunshot  wounds. 

Symptoms. — The  usual  signs  of  fracture  in  con- 
nexion with  some  serious  complication,  such  as 
laceration  of  bladder  or  rectum,  injury  to  the  peri- 
toneum, division  of  arteries  and  veins. 

Treatment. — Keep  the  patient  in  bed  and  treat 
the  complication  on  general  principles.  When 
the  Os-coccygis  is  broken,  the  finger  should  be  in- 
troduced into  the  rectum  and  the  fragments  re- 
placed. 


PRADT1  RES  OF  lir  MERUS.  ^71 

Fractures  of  the  bones  op  the  Superior  Ex- 
tremites. — Fractures  of  the  Humerus. — The  Head, 
anatomical  neck,  surgical  neck,  shaft  and  con- 
dyles of  the  Humerus  may  be  fractured. 

ture  of  the  head.— The  head  ofthe  Humerus 
is  frequently  fractured  by  balls,  though  this  ac- 
cident from  other  causes,  is  very  uncommon.  If 
the  fracture  be  compound  the  fragments  can  readi- 
ly be  felt  with  the  lingers.  The  treatment  under 
these  circumstances,  is  resection.  Boyer  states  that 
there  can  be  no  bony  union  when  the  fracture  is 
is  intra-capsular,  and  that  death  is  generally  the 
alt. 

Anatomical  w^ck.— Causes.— Falls 
and  hi  .•ws.arare  accident. — Symptoms.     The  head 
can  be  fell  in  the  glenoid  cavity;  slight  hollow  be- 
low the  acromion;  axis  directed   inward-:  crepita- 
ion  very  faint;  and  the  bones  shortened  slightly. 
itmcfit. — A  pad  in  the   axilla,  splints   to   the 
.  and  a  sling  to  keep  the  elbow  slightly  raised. 
Fracture  of  the  Surgical  neck. —  Causes. — Falls 
the  hand:  direct  violence,  and  muscular  ac- 

•The  upper  fragment  slightly  elevat- 
ed by  the  muscles  attached  to  the  tuberosities;  the 
upper  end  of  lower  fragment  drawn  inwards  by 
latissimu  pectoralis  major  and  teres  major 

muscles;  humerus  thrown   obliquely   outwards  by 
•id  muscl  sometimes  elevated  so   as   to 

project   beneath   and    in    front    of    the    coracoid 

treatment. —  The   Indications  arc   to   counteract 
the  action  ofthe  opposing  muscles  and  to  keep  the 


372  FRACTURES    OF    HUMERUS. 

fragments  in  position.  Draw  the  arm  from  the 
body  ;  apply  four  paste  board  splints  on  its  sides; 
place  a  large  conical  shaped  pad  with  its  base  up- 
wards, in  the  axilla ;  approximate  the  elbow  to  the 
side  and  retain  it  there  by  strips  of  adhesive  plaster 
or  a  broad  roller  passed  around  the  chest ;  flex  the 
forearm  and  support  it  in  a  sling. 

Fracture  of  the  Shaft. —  Causes. — Falls,  violence; 
muscular  contraction,  &e. 

Symptoms. — Deformity,  preternatural  mobility 
and  crepitus.  There  is  but  little  shortening,  as 
the  weight  of  the  arm  counteracts  it.  If  the  frac- 
ture be  below  the  deltoid  the  inferior  fragment  will 
be  drawn  inwards,  but  it  above  that  point,  out- 
wards. The  limb  is  powerless  and  is  supported 
by  the  patient  at  the  wrist.  The  fracture  may  also 
be  compound,  complicated  or  comminuted,  the 
diagnosis  being  easy  in  each  case.  When  the 
fracture  occurs  just  above  the  condyles  the  lower 
fragment  is  carried  backward  and  upwards  by  the 
action  of  the  triceps. 

Ireatment. — In  simple   fracture,    apply  a  roller 
from  the  fingers  to  the  axilla;    adjust  either   two 
three  or  four  splints,   made   of  paste  board,    sole 
leather  or  thin  wood,  to  the  arm, — one  extending 
from  the  axilla  to  within  an  inch  of  the   condyle, 
another  from  the  shoulder  joint  to  an  inch  above 
the  corresponding  condyle,  a  third  in  front  and  a. 
fourth  behind;  flex  the  forearm  and  support    in    a" 
sling.     Reunion  will  generally  occur  in  a  month. 
When  the  fracture  is  complicated  with  a  division 
of  the  artery,  ligation  in  the  wound,  should  be  im- 
mediately resorted  to.     When  the  fracture  is  corn- 


FRACTURES   OF   HUMERUS.  373 

pound,  the  patient  should  be  put  to  bed,  and  the 
injured  limb  supported  upon  a  pillow,  the  forearm 
being  kept  at  an  obtuse  angle  with  the  arm,  the 
elbow  on  a  level  with  the  shoulder,  and  the  hand 
little  higher  than  the  elbow.  No  bandage  should 
be  applied,  but  support  may  be  given  either  by 
wire  splints — permitting  irrigation — or  two  lateral 
wooden  splints.  The  patient  must  be  kept  per- 
fectly quiet,  so  that  the  upper  fragment  may  not 
be  disturbed  by  any  movement  of  the  trunk. 

When  the  swelling  has  subsided,  and  the  inflam- 
mation has  been  subdued, — the  starch  bandage 
may  be  used  with  advantage. 

Fracture  of  the  Condyles. — The  causes  producing 
Ibis  fracture  are  the  same  as  those  already  referred 
to  under  previous  heads. 

Symptoms. — The  detached  condyle  can  usually 
be  felt  with  the  finger ;  crepitus  is  perceived  on 
bending  the  arm  ;  there  is  pain  at  the  seat  of  injury 
with  deformity.  If  the  inner  condyle  be  fractured 
the  ulna  projects  backward,  but  resumes  its  natural 
position  when  the  arm  is  extended;  while  the 
humerus  advances  in  front  of  the  ulna.  If  the  ex- 
ternal condyle  be  separated  the  joint  is  immovable, 
the  hand  remains  supine,  and  there  is  constant 
semiflexion  of  the  forearm. 

rlreatment. — Ooaptate  the  fragments;  retain  them 
in  position  by  means  of  compresses,  and  strips  of 
adhesive  plaster,  applied  around  the  joint  in  the 
form  of  a  figure  of  eight ;  apply  the  angular  splint; 
and  support  the  forearm  in  a  sling. 
Fractures  of  the  Ulna. — The  Olecranon  process, 
1G 


374  FRACTURES  OF  ULNA. 

coronoid  process  and  shaft  of  this  bone  are  liable 
to  be  broken. 

Fracture  of  the  Olecranon. — Causes. — Direct  vio- 
lence, and  muscular  action. 

Symptoms. — Semiflexion  of  the  limb ;  impossibili- 
ty of  extending  the  forearm  ;  a  hollow  at  the  back 
of  the  elbow;  a  prominence  at  the  posterier  in- 
ferior surface  of  the  arm;  pain,  swelling,  &c. ; 
crepitus  when  the  radius  is  rotated 

Treatment. — Bring  the  separated  parts  into 
position ;  confine  them  by  means  of  compresses 
and  adhesive  strips;  apply  a  wooden  splint  in  front 
of  the  joint;  and  keep  the  arm  extended. 

Fracture  of  the  Coronoid  process. — Causes. — Di- 
rect injury,  as  the  passage  of  the  wheel  of  a  coach, 
or  force  applied  to  the  hand,  impelling  the  ulna 
and  radius  violently  upwards  against  the  lower  ex- 
tremity of  the  humerus. 

Symptoms. — The  ulna  is  carried  backwards  and 
upwards;  the  olecranon  is  prominent;  the  limb 
cannot  be  flexed;  the  detached  bone  can  be  felt 
above  the  elbow;  crepitation,  pain  and  swelling, 
present  themselves. 

Treatment. — Bandage  the  forearm  carefully  from 
the  fingers  and  the  upper  arm  from  the  shoulder 
downwards;  flex  the  forearm  at  a  right  angle;  and 
enclose  the  arm  in  a  tin  case  or  angular  splints. 
Adhesive  plaster  may  be  carried  around  the  joint 
so  as  to  keep  the  fragment  in  position. 

Fracture  of  the  Shaft. — Causes. — Direct  viol- 
ence, counter  stroke,  muscular  action,  &c. 

Synvptoms. — A  marked  depression  at  the  inner 
border  of  the  forearm,  mobility  of  the  fragments, 


FRACT!  RES    OF    ULNA.  375 

crepitation,  pain,    swelling,   and   displacement  of 
the  lower  Fragment. 

Treatment. — Apply  a  long  splint  in  front  with  a 
compress  adjusted  so  as  to  preserve  the  interosse- 
ous space,  and  another  behind, — both  extending 
from  the  elbow  to  the  end  of  the  fingers,  and  wider 
than  the  arm;  have  the  forearm  in  a  position  mid- 
way between  pronation  and  supination;  let  the 
thumb  project  as  a  guide;  and  then  bind  the  splints 
to  the  forearm  by  means  of  a  roller  bandage.  Or 
the  hand  may  be  permanently  inclined  towards  the 
thumb,  by  .means  of  two  splints  the  extremities  of 
which  arc  made  somewhat  sloping  from  behind 
forwards. 

Fracture  of  tht  Radius. — The  superior  extremity, 
shaft  and  inferior  extremity  of  this  bone  may  be 
broken.  Fracture  ;;f  Superior  Extremity. — Causes. 
Direct  violence. 

Symptoms. — Deformity  below  the  joint;  projec- 
tion of  the  upper  end  of  the  lower  fragment;  im- 
possibility of  rotating  the  forearm;  the  refusal  of 
the  upper  fragment  to  follow  the  motions  of  the 
lower,  &c. 

Treatment. — Place  the  limb  at  right  angles  with 
the  arm  in  a  position  midway  between  pronation 
and  supination,  and  employ  the  same  splints  as 
for  fracture  of  both  bones  of  the  forearm. 

Fracture  of  the  Shaft. —  Causes. — Violence  direct 
or  indirect. 

Symptoms. — The  fragments  approach  the  inter- 
osseous space ;  while  there  is  more  or  less  of  de- 
formity, preternatural  mobility,  absence  of  thepow- 
er  to  pronatc  and  supinate  the  army,  and  crepitus. 

Treatment. — Precisely  the  same  as  for  fracture 


FRACTURES    OF  RADIUS. 

oftheulna.  When  the  curved  or  pistol  handlo 
splints  arc  used  they  should  bo  sloped  from  before 
backwai 

Tin  !  tdius  and  Ulna  are  frequently 

fractured  together  by  a  direct  blow  or  indirect 
violence.  The  fragments  arc  drawn  inwards  by 
the  pronator  quadratus,  tending  to  destroy  the  in- 

readily  made  by 
extension  from  the  wrist,  and  retention  is  effected 
by  means  of  spliuts,  padded  80  as  to  preserve  the 
interosaeous  id  extending  from  the  elbow 

to  "the  end  of  the  The  splints,  should  b 

wider  than  the  arm,  and  no  attempt  should  be 
made  to  I  the  limb  before  their  application, 

aid  be  in  tion  midway  between 

pronation  and  supination  and  the    thumb  left  out 

to  preserve  the 
intero  pace  and  to   prevent  the  upper  frag- 

ment of  the  radius  from  being  too  much  supinated. 

Fracture  of  low  the  Radius. — The  radius 

may  be  broken  cither  directly  at  the  joint,  or  an 
inch  and  a  half  above  it.     The  former  is  known  as 
Barton's  and  the  latter  as  Colic's  fracture. 
Causes.     Violence  either  direct  or  indirect. 

Symptoms, — The  lower  fragment  is  drawn  up- 
wards and  backwards  behind  the  upper  fragment, 
by  the  combind  action  of  the  supinator  longus  and 
the  flexors  and  extensors  of  the  thumb  and  carpus, 
producing  a  prominence  on  the  back  of  the  wrist 
and  a  deep  depression  behind.  The  upper  frag- 
ment projects  forward,  and  is  drawn  by  the  prona- 
torquadratus  in  close  contact  with  the  ulna,  causing 
a  projection  on  the  anterior  surface  of  the  forearm 


FRACTURES  OF  RADIUS.  3<7 

just  above  the  carpus — all  the  usual  signs  of  frac- 
ture are  also  present. 

Ireatment. — The  treatment  -    in   Hexing 

the  forearm,  nnd  making  powerful  extension  from 
the  wrist  and  elbow,  depressing  at  the  same  time 
the  radial  side  of  the  hand,  and  retaining  the  parts 
m  position  by  compressing  each  projecting  point 
and  the  use  of  well  padded  pistol  shaped  splints- 
Bond's  and  Smith's  splints  are  regarded  as  the  best 
for  this  fracture. 

In  compound  fractures  of  the  forearm,  the  pa- 
tient should  be  put  to  bed,  and  the  arm  placed 
upon  a  pillow  or  in  a  well  padded  fracture  box. 
Cold  water  should  be  allowed  to  drip  upon  it  from 
above.  Care  should  be  taken  to  keep  the  arm 
semipronated,  to,  ensure  the  parallelism  of  the 
bones,  and  to  have  the  pillow  made  firm  by  placing 
a  wide  board  beneath  it.  When  the  swelling  and  in- 
flammation have  subsided,  the  arm  may  be  placed 
in  a  starch  bandage  or  on  a  wide  splint  and  sup- 
ported by  a  sling,  when  the  patient  can  walk  about. 

Fracture  of  the  Carpal  Bones  should  be  treated  on 
general  principles. 

Fractures  of  the  Metacarpal  Bones. —  Causes. — Di- 
rect and  indirect  blows,  gunshot,  wounds,  &c. 

Symptoms. — One  fragment  is  elevated  above  the 
other.  The  deformity  can  be  readily  reduced  but 
again  shows  itself  when  the  pressure  is  removed. 

Treatment. — Make  moderate  extension  upon  the 
linger  corresponding  to  the  broken  bone;  force 
the  fragments  into  position ;  apply  paste  board 
splints  to  the  palm,  back  oi'  the  hand  and 
fingers.     The    splints    should    be    well    padded. 


378  FRACTURES   OF   FINGERS. 

Fractures  of  the  fingers  can  be  readily  detected. 

"When  the  extreme  phalanx  is  broken,  the  re- 
medy is  amputation.  When  the  other  phalanges 
are  broken,  coaptation  may  be  ensured  by  exten- 
sion, and  the  fragments  retained  in  position  by 
means  of  a  splint  made  of  paste  board  or  felt, 
moulded  accurately  to  either  the  dorsal  or  palmar 
aspect  of  the  finger.  Compound  fractures  should 
be  treated  on  general  principles.  Conservative 
Surgery  holds  a  proud  pre-eminence  in  this  con- 
nexion, and  the  operator  should  endeavor  to  save 
as  much  of  the  member  as  possible. 

Fractures  of  tJte  Femur. — This  bone  may  be  bro- 
ken either  in  its  upper  extremity,  in  its  shaft  or  in 
its  inferior  extremity. 

Fracture  of  the  neck,  internal  to  the  capsular 
ligament.  Causes. — Direct  violence,  indirect  vio- 
lence, such  as  slipping  off  the  edge  of  a  curbstone, 
gunshot  wounds,  &c. 

Symptoms. — Slight  shortening  of  the  limb  ;  ever- 
sion  of  the  foot  from  the  combined  action  of  the 
external  rotator  muscles,  together  with  the  psoas, 
iliacue;  preternatural  mobility — shown  by  rotating 
the  limb  upon  its  axis,  flexing  it  upon  the  pelvi'Bj 
or  extending  it  behind  the  line  of  the  sound  limb  ; 
change  of  position  in  the  grent  trochanter — being 
drawn  upwards  towards  the  ilium  and  in  close 
contact  with  the  acetabulum,  and  also  describing 
a  smaller  segment  when  the  limb  is  rotated ; 
change  of  attitude — the  body  is  thrown  forward  ; 
the  sound  limb  is  firmly  planted  on  the  floor,  the 
unsound  one  hangs  off  in  a  constrained  and  awk- 
ward manner — the  foot   and   knee  being  everted, 


-  FRACTURES  OF  FEMUR.  379 

the  leg  is  supported  upon  the  ball  of  the  toes,  while 
the  heel  is  elevated  two  or  three  inches,  the  natu- 
ral prominence  of  the  hip  is  destroyed,  and  the 
patient  cannot  walk.  This  accident  usually  oc- 
curs in  persons  of  advanced  age,  because  the  neck 
of  the  bone  is  more  horizontal  at  that  period,  and 
the  bone  contains  more  earthly  matter.  The  un- 
ion between  the  fragments  is  always  of  a  fitoro-lig- 
amentons  nature,  when  it  takes  place  at  all. 

Treatment. — The  plan  recommended  by  Sir  A.st- 
ley  Cooper,  and  persue'd  by  most  surgeons,  is  to 
keep  the  patient  quietly  in  bed  for  two  or  three 
weeks  and  then  permit  him  to  walk  about  on 
crutches.  The  long  splint  such  as  will  be  descri- 
bed in  connexion  with  factiires  of  the  shaft,  may 
also  be  employed.  In  compound  fractures  at 
this  point,  resection  may  be  attempted  under  (he 
modifications  alluded  to  in  another  portion  of  this 
volume. 

Fracture  at  the  base  of  the  neck,  (extra  capsular.) 
Causes. — Falls  upon  the  hip;  blows:  falls  upon 
the  foot  or  knee  ;  gunshot  wounds,  &c. 

Symptoms. — Shortening-:  eversion  of  the  foot  or 
knee;  mobility  of  the  fragments;  distinct  crepita- 
tion ;  elevation  of  the  trochanter:  severe  pain; 
great  swelling;  considerable  shock  followed  by 
excessive  reaction. 

Treatment. — Place  the  limb  in  the  straight  posi- 
tion ;  apply  splints  on  either  side  :  and  make  exten- 
sion and  counter  extension  according  t<>  the  plans 
which  will  be  more  fully  explained  when  fractures 
of  the  slud't  are  considered.  The  foot  should  be 
inclined  slightly  outwards  to  relax  the  rotator  mus- 


380 


FRACTURES   OF  FEMUR. 


cles  and  great  care  should  be  taken  to  prevent 
over  lapping  of  the  fragments  or  angular  deformi- 
ty. Continue  the  dressings  for  at  least  five  weeks. 
It  is  a  matter  of  great  moment  to  distinguish 
between  intra-capsular  fracture  and  iliac  disloca- 
tion and  between  fracture  within  and  without  the 
capsular  ligament.  The  following  signs  will  es- 
tablish the  diagnosis. 


INTRA-CAPSULAR  FRACTURE. 

1.  Occurs  generally  in  old 
persons  and  most  common  in 
women. 

2.  Produced  usually  by  slight 
causes. 

3.  Foot  strongly  everted. 

4.  Great  shortening,  which 
returns  readily  after  reduction 

5.  Crepitation. 

6.  Preternatural  mobility. 


INTRA-CArSULAR  FRACTURE. 

1.  Slight  shortening  which 
gradually  increases  to  two 
inches  and  upwards. 

2.  Crepitation  indistinct. 

3.  Function  impaired. 

4.  Trochanter  moves  on  rO' 
tation,  as  it  were,  upon  a  pivot 


ILIAC  DISLOCATION. 

1.  Most  frequently  in  adult 
and  middle  life — and  is  com- 
mon to  both  88X68. 

2.  Produced  by  great  vio- 
lence. 

3.  The  foot  is  inverted. 

4.  Shortening  does  not  re- 
turn after  reduction. 

5.  No  crepitation. 

6.  The  bone  is  fixed  and  in 
a  constrained  position. 


EXTRA-CAPSULAR  FRACTURES. 

1.  Shortening  is  lees  but 
more  persistent. 

2.  Crepitation  very  distinct. 

3.  Loss  of  function  complete. 

4.  The  trochanter  is  only 
partially  separated  and  imper- 
fectly obeys  the  movements  of 
the  limb. 

5.  Pain  severe  and  located 
near  the  great  trochanter. 

6.  Severe  contusion  with 
considerable  swelling,  ecchy- 
mosis  and  discoloration. 

In  compound  fractures   from   gunshot  wounds 

resection  may  possibly  be  resorted  to,  but  the  wisest 

plan  is  to  attempt  to  save  the  limb.     After  much 


5.  Pain  greatest  in  the  direc- 
tion of  the  small  trochanter. 

G.  But  slight  swelling,  con- 
tusion or  dislocation. 


FRACTURES  OF  FEMUR.  381 

observation  and  reflection,  I  am  convinced  that 
the  probabilities  of  a  favorable  issue,  are  much  in- 
creased by  the  rejection  of  all  appliances  in  the 
way  of  inclined  planes,  extending  and  counter  ex- 
tending forces,  &c.  They  tend  to  increase  irrita- 
tion and  inflammation,  to  interfere  with  water 
dressings,  and  the  free  discharge  of  pus,  and  to 
render  the  patient  more  uncomfortable,  while  they 
do  not  secure  better  results  so  far  as  the  usefulness 
and  symmetry  of  the  limb  arc  concerned.  Smith's 
anterior  splint  may  be  tried  in  the  premises,  but 
if  the  case  does  not  progress  favorably,  all  dressings 
should  be  removed,  and  the  limb  placed  on  such  a 
position  upon  pillows  as  will  best  secure  the  com- 
fort of  the  patient.  The  preservation  of  the  suffer- 
er's life  is  the  great  desideratum,  while  the  useful- 
ness and  symmetry  of  the  member  arc  matters  of 
secondary  consideration  in  this  connexion. 

Fracture  of  the  shaft  in  its  upper  third.  The 
most  common  scat  of  this  fracture  is  from  two  and 
a  half  to  three  inches  below  the  trochanter  minor. 

Causes. — Direct  or  indirect  violence,  &c. 

/Symptoms. — The  upper  fragment  is  carried  for 
wards  by  the  action  of  the  psoas  and  lliacus  inter- 
ims, and  at  the  same  time  everted  and  drawn  out- 
wards by  the  external  rotator  and  glutei  muscles, 
causing  a  marked  prominence  at  the  outer  side  of 
the  thigh  and  great  pain  from  the  laceration  oJ  the 
muscles;  the  lower  fragment  is  drawn  upwards, 
by  the  rectus,  biceps,  semi-membranosus  and  semi- 
tendinous muscles,  whilst  its  upper  end  is  thrown 
outwards  and  its  lower  end  inwards  by  the  pecti- 
neus  and  adductor  muscles ;  crepitation,  preterna- 
16b 


382  FRACTURES  OF  FEMUR. 

tural  mobility  and  the  ordinary  signs  of  fracture, 
are  also  present. 

Ireatment. — This  fracture  may  be  treated,  when 
simple,  either  by  direct  relaxation  of  all  the  oppo- 
sing muscles  by  means  of  the  double  inclined  plane, 
or  by  overcoming  the  contraction  of  the  muscles 
by  the  use  of  the  long  splints.  Of  these  two  plans 
of  treatment  preference  should  be  given  to  that  for 
relaxing  the  muscles,  which  can  be  most  success- 
fully accomplished  by  the  doubled  inclined  plane. 
Mode  of  procedure.  Obtain  if  possible  a- proper 
bed ;  apply  a  roller  from  the  toes  to  the  groin  ; 
secure  two  splints  made  of  binder's  boards,  sof- 
tened in  hot  water  and  nearly  meeting  in  front, 
to  the  thigh;  lay  the  limb  over  the  double  inclined 
plane,  which  should- be  well  cushioned  :  attach  the 
foot  to  the  foot  board,  so  as  to  prevent  inversion 
or  eversion  of  the  member  ;  raise  the  body  slightly 
so  as  to  relax  the  psoas  and  iliacus  muscles  ;  adjust 
the  angle  beneath  the  knee  in  such  a  manner  as  to 
relax  the  muscles  by  which  the  lower  fragment  is 
kept  out  of  position,  and  to  keep  the  two  frag- 
ments upon  the  same  plane,  and  in  the  same  line ; 
bind  the  limb  to  the  apparatus  by  means  of  a 
roller  bandage  ;  and  retain  it  in  positiou  either  by 
means  of  pegs  placed  on  the  side,  or  by  side  boards 
so  arranged  as  to  form  with  the  splint  a  kind  of 
trough.  By  means  of  Smith's  anterior  splint 
the  conjoint  advantages  of  relaxation  and  exten- 
sion may  be  secured.  This  apparatus  is  nothing 
more  than  a  double  enclined  plane  made  of  strong 
iron  wire  as  long  as  the  limb  and  applied  anteriorly, 
with  cords  passing  from,  the  upper  and  lower  cross 


FRACTURES  OF  FEMUR.  383 

wires  and  uniting  into  a  common  one  which  passes 
in  an  oblique  direction  to  the  wall  and  suspends  the 
limb.  The  muscles  are  not  only  relaxed,  as  by  the 
ordinnry  inclined  plane,  but  all  ten  den  C}7  to  con. 
traction  is  obviated  by  the  obliquity  of  the  cord, 
which  acts  as  the  extending  force  below,  and  by 
the  weight  of  the  body,  which  serves  as  the  coun- 
ter extending  force  above.  The  suspension  of  the 
limb  precludes  such  displacements  as  are  likely  to 
occur  in  consequence  of  the  movements  of  the 
body,  thus  securing  a  much  greater  latitude  in  that 
regard  and  contributing  materially  to  the  comfort 
of  the  patient. 

1  f  (here  be  trouble  in  keeping  the  upper  frag- 
ment in  place,  a  compress  or  fln  additional  splint, 
may  be  applied  above  it,  so  as  to  force  it  in  posi- 
tion. Care  must  be  taken  not  to  apply  the  blind- 
age too  tightly,  or  to  permit  the  bed  clothes  to  rest 
upon  the  limb. 

In  compound  fractures  of  the  upper  third  of  the 
thigh  from  gunshot  wounds,  the  same  principles 
will  apply  as  enumerated  above.  The  long  splint 
tends  to  augment  both  the  local  and  constitutional 
irritation,  while  the  double  euclined  plane,  and 
even  Smith's  apparatus,  soon  become  irksome  to 
the  sufterer  and  tend  to  interfere  with  the  free 
escape  of  pus,  by  causing  it  to  gravitate  towards 
the  body.  The  better  plan  is  to  reject  them  in  the 
lii>t  instance,  to  place  the  limb  in  a  comfortable 
position  upon  a  pillow,  to  resort  at  once  and  per- 
sistently to  the  cold  water  treatment,  and  to  direct, 
everj  energy  towards  the  preservation  of  the  pa 
tieufs  life,  reserving  tbe  question  of  deformity  for 


384:  FRACTURES  OP  FEMUR. 


a  later  period  in  the  history  of  the  case.  An  at- 
tempt should  be  made  to  save  the  limb  on  account 
of  the  extreme  fatality  of  amputations  in  this  lo- 
cality. 

Fracture  of  the  middle  third.  Causes. — Same  as 
last. 

Symptoms. — The  superior  fragment  overlaps  the 
inferior  ;  the  lower  end  of  the  superior  fragment 
is  drawn  inwards  and  upwards  by  the  flexor  mus- 
cles ;  the  limb  is  shortened  from  2  to  4  inches,  and 
everted  ;  the  upper  end  of  the  inferior  fragment 
forms  a  projection  on  the  forepart  of  the  thigh  ; 
while  mobility,  crepitus,  pain  and  swelling  contri- 
bute their  quota  to  the  perfection  of  the  diagnosis. 

Ireatment. — Numerous  plans  have  been  de- 
vised for  the  treatment  of  this  fracture,  but  the 
following  seems  to  possess  the  greatest  advantages. 
Directions  :  lay  the  perineal  band  in  its  place  and 
place  four  pieces  of  bandage  transversely  where  the 
broken  thigh  is  to  rest ;  over  these  lay  a  splint  as 
wide  as  the  diameter  of  the  thigh,  well  padded, 
and  long  enough  to  reach  from  the  tuberosity  of 
the  ischium  to  the  lower  margin  of  the  ham ;  lay 
the  patient  upon  the  bed,  with  his  thigh  reposing 
upon  the  back  splint  and  his  head  and  body -slight- 
ly raised ;  make  an  assistent  seize  the  knee  firmly 
and  make  moderate  traction,  so  as  to  steady  the 
limb  ;  lay  long  strips  of  adhesive  plaster  upon  the 
leg  from  the  knee  down,  forming  loope  below,  and 
and  secured  to  the  limb  by  other  strips  and  a  roller 
carried  spirally  around  it,  taking  care  to  protect  the 
ankles  by  small  pieces  of  cotton  batting ;  apply 
then  a  roller  from  the  toes  to  the  ham ;  lay  the 


FRACTURES   OF  FEMUR.  385 

long  splint  on  the  outside  of  the  limb,  extending 
from  four  to  five  inches  below  the  foot  either  to  the 
crest  of  the  ilium,  according  to  Desault,  or  to  the 
axilla  as  suggested  by  Physick ;  adjust  the  perineal 
baud,  and  attach  the  upper  extremitj  of  the  long 
splint  to  the  body  by  menus  of  a  band  passed  around 
it ;  twist  the  adhesive  strips  below  the  foot  into  a 
small  rope,  attach  them  to  the  extending  screw  in 
the  foot  piece,  and  tighten  them  moderately  so  that 
the  assistant  may  release  his  hold  upon  the  knee  ; 
lay  a  padded  splint  upon  the  inside  of  the  limb 
extending  from  the  groin  to  a  point  immediately 
below  the  knee ;  apply  another  splint  in  front  ex- 
tending front  the  groin  to  within  one  inch  of  the 
knee  ;  bring  up  the  four  transverse  bands,  previ- 
ously placed  under  the  limb,  so  as  to  include  the 
three  short  splints  and  the  l«ng  splint;  then  carry 
extension  to  the  utmost  point  of  tolerance  ;  fill  up 
all  the  inequalities  and  insterstices  with  soft  cot- 
ton ;  and  complete  the  dressing  by  applying  a 
roller  bandage  over  the  splints  from  the  foot  to  the 
groin.  Increase  the  extension  daily  for  a  week, 
and  then  maintain  it  until  union  is  complete. 
About  the  twenty  eighth  day  relax  the  extension, 
and  lift  the  limb  regularly,  rubbing  and  gently 
Hexing  the  knee.  For  two  months  the  patient 
should  walk  on  crutches  and  bear  but  little  weight 
upon  the  limb. 

In  compound  fractures,  especially  where  there  is 
much  comminution,  but  little  advantage  can  be 
expected  from  extension  with  the  long  splint  until 
the  violence  of  the  inflammatory  action  has  subsi- 
ded ;  while  the  inclined  plane  is  liable  to  the  ob- 


S86  FRACTURES  OF  FEMUR. 

jections  which  have  already  been  referred  to. 
Gentle  extension  may  be  attempted  by  applying 
and  securing  adhesive  strips  to  the  leg,  then  attach- 
ing a  weight  to  them  and  suspending  it  over  a  pul- 
ley at  the  foot  of  the  bed  ;  but  if  the  case  does  not 
progress  favorably  even  this  should  be  discarded 
and  the  fracture  treated  upon  the  plan  suggested 
in  connexion  with  similar  injuries  in  the  upper 
bird.  For  statistical  information  in  regard  to  the 
treatment  of  "compound  fractures  of  the  femur,  see 
table  "I,"  of  the  Appendix.  Malgaigne  declares 
that  in  the  attempt  to  save  the  limb,  under 
these  circumstances,  no  greater  risk  is  run  than  in 
amputating  it.  This  is  certainly  an  extreme  view 
of  the  ease,  as  is  established  by  the  statistics  of 
Stone  and  Baudens, — who  themselves  arc  advocates 
of  conservative  surgery — in  connexion  with  these 
accidents.  The  femur  has  frequently  been  resec- 
ted for  injuries  of  this  character,  but  the  expedi- 
ency of  this  procedure  is  very  questionable. 

Fracture  of  the  Lower  third — immediately  above 
the  condyles.     Causes,     Direct  or  indirect  violence. 

Symptoms. — The  lower  fragment  may  be  felt  in 
the  popliteal  space  being  drawn  back  by  the  gas- 
trocnemius, soleus  and  plantaris  muscles,  and  up- 
wards by  the  rectus  ;  the  end  of  the  upper  fragment 
is  drawn  inwards  by  the  pectineous  and  adductor 
muscles,  and  forwards  by  the  psoas  and  iliaeus; 
the  limb  is  shortened;  while  crepitation,  pain, 
swelling,  &c.,  are  also  present. 

Treatment. — The  indication  is  to  relax  the  oppos- 
ing muscles,   and   approximate  the  broken  frag- 


FRACTURES.  OF  FEMUR.  387 

raents.  This  is  accomplished  by  placing  the  limb 
upon  the  double  inclined  plane. 

The  principal  circumstances  which  demand  the 
attention  of  the  Surgeon  in  connexion  with  frac- 
tures of  the  shaft  of  the  femur  arc  : 

L  The  ends  of  the  broken  bono  must  be  steadily 
kept  upon  the  same  plane  and  in  a  line  with  each 
other. 

2.  Care  must  be  taken  that  no  shortening  occurs. 
The  extending  and  counter  extending  bands  should 
l>e  watched  and  tightened  when  necessary. 

8.  The  limb,  should  be  placed  in  a  slightly 
elevated  position. 

4.  It  is  important  to  keep  as  much  pressure  off 
the  heel  as  possible  in  order  to  prevent  sloughing, 
and  ulceration. 

5.  The  perineal  band  must  be  carefully  watched 
and  care  taken  to  prevent  it  ironi  excoriating  the 
parts  beneath. 

6.  The  bandage  should  not  be  applied  loo 
speedily,  tightly  or  irregularly,  and  in  compound 
fractures  should  be  dispensed  with.  The  starch 
bandage  may  frequently  be  employed  to  great  ad- 
vantage. 

7.  The  bed  cloths  must  be  kept  oft  the  fractur- 
ed limb,  lest  they  disturb  the  fragments. 

8.  Passive  motion  of  the  neighbouring  joints 
should  be  undertaken  at  the  end  of  the  twenty 
eighth  day. 

Fiatiarc  of  / In  Patella. — Causes. — Direct  injury, 
as  a  fall  or  blow;  indirect  violence;  and  muscular 
contraction. 

Symptoms. — In  transverse    fracture,    the    upper 


388  FRACTURES   OF   PATELLA. 

fragment  is  displaced ;  the  aspect  of  the  limb  is 
changed ;  the  limb  cannot  be  extended ;  there  is 
some  pain,  but  no  crepitation. 

treatment. — Extend  the  leg;  elevate  the  foot; 
bring  the  fragments  together  and  retain  them  in 
apposition  by  means  of  adhesive  strips;  and  place 
the  limb  upon  an  inclined  plane. 

Fracture  of  the  libia. — The  shaft  of  the  tibia  is 
most  frequently  broken  obliquely  at  the  lower 
fourth  of  the  bone,  by  direct  or  indirect  violence. 

Symptoms. — If  the  fracture  has  taken  place  from 
above  downwards  and  forwards  the  fragments  ride 
over  one  another,  the  lower  fragment  being  drawn 
backwards  and  upwards  by  the  muscles  of  the  calf; 
while  the  pointed  extremity  of  the  upper  fragment 
projects  forwards  beneath  or  through  the  integu- 
ment. If  the  direction  of  the  fracture  is  the  re- 
verse of  this,  the  pointed  extremity  of  the  lower 
fragment  projects  forwards,  riding  over  the  lower 
end  of  the  upper  one.  There  is  but  little  crepita- 
tion, and  not  much  pain.  The  internal  malleolus 
is  most  frequently  broken  off  about  the  centre  of 
that  process,  in  an  oblique  direction. 

treatment. — Bend  the  knee  so  as  to  relax  the 
muscles;  bring  the  fragment  in  apposition;  apply 
adhesive  straps  from  the  point  of  fracture,  and 
form  a  loop  below  the  foot ;  tie  a  cord  to  this 
loop,  with  a  weight  attached  to  it,  and  pass  it  over 
a  small  wheel  at  the  foot  of  the  bed;  when  inflam- 
mation has  subsided ;  apply  the  starch  bandage 
and  cut  off  the  straps  close  to  the  foot.  In  coin- 
pound  fractures,  the  same  plan  may  be  adopted, 
taking  care  to  leave  the  wound  uncovered.     The 


FRACTURES  OF  TIBIA.  389 

fracture  box,  filled  with  bran  may  also  be  employ- 
ed. An  admirable  plan  is  to  suspend  the  leg  in  a 
sling  reaching  from  the  knee  to  the  foot.  The 
wound  should  be  treated  on  general  principles. 

Fractures  of  /he  Fibula. — Fractures  of  the  head 
and  shaft  of  the  bone  are  so  readily  detected  and 
easily  treated  that  no  particular  discription  is  ne- 
cessary. When  the  fracture  occurs  in  the  inferior 
fifth  of  the  ,bonc  the  accident  is  a  more  serious 
one.  Causes.  Forcible  abduction  of  the  foot,  such 
as  occurs  in  falls;  and  direct  violence. 

Symptoms. — When  the  fibula  alone  is  broken, 
there  will  appear  slight  eversion  of  the  foot;  de- 
pression at  the  seat  of  injury  ;  and  change  in  the 
aspect  of  the  joint.  When  the  malleolus  is  broken 
off,  or  when  the  tibia  has  given  way  a  short  dist- 
ance above  the  articulation,  the  foot  seems  to  be 
dislocated  outwardly;  the  malleoli  are  widely  se- 
parated; a  deep  pression  in  the  line  of  fracture 
presents  itself;  the  foot  is  unusually  movable, 
while  its  external  margin  is  elevated  and  its  in- 
ternal depressed;  crepitation  can  be  heard;  while 
there  is  considerable  pain,  swellingand  ecchymosis. 

Irealment. — The  indication  is  to  maintain  the 
foot  in  a  position  the  reverse  of  that  which  is  caus" 
cd  by  the  injury.  This  is  accomplished  by  Du- 
puytren's  apparatus,  which  consists  of  a  light 
wooden  splint  and  a  wedged  shaped  cushion, — the 
former  reaching  from  the  upper  third  of  the  leg  to 
about  three  inches  below  the  sole  of  the  foot,  and 
the  latter  from  the  same  point  to  a  level  with  the 
ankle.  Bandage  the  limb,  but  do  not  compress  it 
opposite  the  site  of  fracture;  stretch  the  apparatus 


390  FRACTURES   OF   TIBULA. 

along  its  inner  surface,  with  the  tapering  end  of 
the  pad  upwards  ;  and  secure  it  first  above  and  then 
below,  carrying  the  roller  around  the  foot  and  ankle 
in  such  a  manner  as  to  turn  the  internal  margin  of 
the  foot  upwards  and  inwards.  The  limb  may 
then  be  kept  extended,  or  half  bent  upon  a  pillow. 
Attempt  passive  motion  at  the  end  of  a  week. 

Both  the  libia  and  Fibula  may  be  broken  contem- 
poraneously. If  the  fracture  be  transverse,  there 
is  no  danger  of  deformity;  but  if  oblique  there  will 
be  considerable  shortening.  In  oblique  fractures, 
therefore  extension  and  counter  extension  must  be 
made  and  persisted  in  until  union  has  taken  place, 
while  the  simple  fracture  box  will  answer  for 
transverse  fractures,  provided  the  great  toe  is  kept 
constantly  on  a  line  with  the  inner  border  of  the 
patella. 

Fractures  of  the  ioot. — The  calcaneum  may  be 
broken  by  direct  violence.  There  is  always  con- 
siderable contusion  and  laceration  of  the  soft  parts. 
The  signs  by  which  this  accident  may  be  determin- 
ed are  a  hollow  at  the  heel;  a  protuberance  at  the 
lower  and  hack  part  of  the  leg;  and  the  im- 
possibility of  extending  the  foot.  The  fragments 
should  be  brought  together  and  a  complete  relaxa- 
tion of  the  muscles  of  the  calf  secured,  by  keeping 
the  leg  in  a  permanently  extended  condition.  In 
fractures  of  the  other  bones  there  is  no  displace- 
ment. 

Experience  teaches  that  in  gunshot  wounds  of 
the  foot  involving  a  fracture  of  its  bones,  there  is 
always  danger  to  lie  apprehended,  however  seeming- 
ly insignificant  the  injury.     The  bones  from  their 


FRACTURES  OF  TARSAL  BONES.  391 

peculiar  conformation,  are  easily  shattered,  each 
fragment  becoming  the  focus  of  an  extensive  in- 
flammation, which  speedily  produces  pus  in  large 
qualities.  In  consequence  of  the  thickness  of  the 
fascia1,  the  purulent  matter  does  not  readily  escape, 
but  burrows  in  every  direction,  causing  intense 
pain,  and  great  nervous  irritation,  and  inducing 
pyaemia  with  all  its  frightful  consequences. 

If  the  ball  does  not  pass  entirely  through  the 
foot,  it  should  be  immediately  sought  tor,  and  a 
counter  opening  made,  if  possible,  to  facilitate  the 
discharge  of  pus.  The  endcrmic  exhibition  of 
morphia  may  also  be  resorted  to  for  the  purpose 
of  relieving  the  pain  incident  to  the  wound,  of 
preventing  the  development  of  tetanic  symptoms, 
and  of  securing  quietude  and  sleep  to  the  patient. 
The  foot  should  be  kept  in  an  elevated  position 
until  the  development  of  pus,  but  not  longer,  and 
the  wound  treated  on  general  principles. 


APPENDIX. 


393 


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400 


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